Rosepark Care Home Case Study

Fire safety procedures at a care home for the elderly where an electrical fire claimed the lives of 14 residents were "systematically and seriously defective", a fatal accident inquiry has ruled.

In a 1,000 page report published after Scotland's longest running FAI, sheriff principal Brian Lockhart detailed a series of safety defects at the Rosepark care home in Uddingston, Lanarkshire, that he said contributed to the deaths of the 14 elderly residents in January 2004. Some or all of the deaths could have been prevented if the home had had a suitable fire safety plan in place, he found. The fire broke out in a cupboard of the care home. Ten of the residents died at the scene, and four subsequently died in hospital. The eldest was 98 and the youngest 75. In his report the sheriff principal said staff at the home had not been properly trained in fire safety and fire drills, the maintenance of the electrical installation where the fire broke out was defective, and the management of fire safety at the home was "systematically and seriously defective".

Three of the staff on duty on the night of the fire had been shown a fire safety video once but apart from that none of the staff on duty had received any fire training or experienced a fire drill at the home, and none had been trained to use a fire extinguisher. The sheriff principal said: "The way the staff responded on the night of 31 January 2004 was just what might be expected of staff who had not received adequate fire training and who had, by reason of exposure to false alarms, become complacent. Had the staff been properly trained in a matter consonant with the task that would face them in that emergency situation, they would have behaved quite differently and that, either on its own, or in conjunction with other changes which would have been put in place had the system of fire safety management not been defective, would have avoided some or all of the deaths."

The report noted that vital time was lost when staff took nine minutes to call the fire brigade. The home's practice meant a member of staff had to find the source of the blaze before calling 999. There was an extra delay of just over four minutes when the fire brigade went to the wrong entrance to the home because the postal address was different.

The elderly residents who died were: Dorothy McWee, 98, Tom Cook, 95, Isobel MacLachlan, 93, Julia McRoberts, 90, Annie Thompson, 84, Helen Crawford, 84, Margaret Lappin, 83, May Mullen, Helen Milne, Anna Stirrat, and Mary McKenner, all 82, Robina Burns, 89, Isabella MacLeod, 75, and Margaret Gow, 84.

The sheriff principal said that since the fire the lessons of the tragedy had been taken on board by the management of the home and the deficiencies identified "substantially eradicated". A spokesman for the owners of Rosepark care home said: "Our legal team is studying the determination issued by sheriff principal Brian Lockhart. We have nothing further to add at present."

An attempt to prosecute the home's owners over alleged safety breaches collapsed in 2007 after a judge dismissed the charges. A second case raised in 2008 was also dropped.

The report also found deficiencies in the working of Lanarkshire Health Board with regard to identifying fire risks at the home. The board was responsible for inspecting the Rosepark home between 1992 and 2002. In a statement, NHS Lanarkshire said it would need time to study the report and extended its deepest sympathies to the families and friends of those who died. "While we do not currently have any defined responsibility for fire safety within the independent care sector, in light of the determination we will ensure owners of establishments that we contract with are fully aware of their responsibilities in this area," the statement added.

FIRE precautions and training at a Lanarkshire nursing home where 14 elderly residents died in a blaze were "systematically and seriously defective", according to the findings of a fatal accident inquiry.

None of the four night staff on duty at Rosepark Care Home in Uddingston when the blaze broke out in the early hours of January 31, 2004, had ever been on a fire drill, while owner Thomas Balmer failed to ensure that a “suitable and sufficient risk assessment” was carried out at the premises.

In his 1001-page determination on the tragedy, published yesterday, Sheriff Principal Brian Lockhart notes that “some or all of the deaths” may have been avoided if the fire panel in reception had been labelled correctly. In fact, the zoning diagram that was supposed to help staff identify the location of a fire did not match the actual layout of the home’s fire compartments. As a result, staff believed the fire was concentrated in the stairwell and lift shaft area of the lower ground floor, instead of the upstairs linen cupboard.

Mistakes during the home’s construction in 1991 meant fire dampers were not fitted in the building’s ventilation shafts, allowing smoke to travel through the building.

Sheriff Principal Lockhart said: “Instead of going to Corridor 4 where the fire actually was, staff investigated the foyer area and downstairs. In effect they investigated all parts of the building other than where the fire actually was.”

Poor staff training also contributed to a nine-minute delay between the alarm sounding and the nurse in charges phoning the fire brigade.

“None of the staff on duty received any fire training. None of them had experience of a fire drill at Rosepark. None were given any training in the use of fire extinguishers. Isobel Queen, who was expected to be the nurse in charge that night and to take command of the situation, had been given no training in her role,” said the Sheriff Principal

However, Sheriff Principal Lockhart said it was the failure of owner Thomas Balmer to ensure that Rosepark underwent a “suitable and sufficient” risk assessment that ultimately led to the tragedy. Although Mr Balmer had recruited health and safety consultant James Reid to inspect the home, no action was taken by the managers to follow through on his recommendations.

Nonetheless, Mr Reid’s report was flawed, said the Sheriff Principal. “His document critically failed to identify the residents as persons at risk in the event of fire; it paid limited attention to the means of escape, the protection of the means of escape and the arrangements for evacuation.”

The “worst-case scenario” of a fire breaking out at night was not covered.

Sheriff Principal Lockhart said: “The number of persons accommodated in Corridor 4, namely 14, were too many for an effective evacuation. This ought to have been obvious to a fire safety professional.”

Mr Reid’s report also failed to address dangers such as residents’ bedroom doors being left open overnight, and the storage of aerosol canisters in an unsecured cupboard next to a “source of ignition” -- a fuse box.

In addition, Mr Balmer did not ensure the home’s electrical installations were ever checked in line with regulations from the Institute of Electrical Engineers (IEE), while documentation detailing an alleged arrangement between Rosepark and electrician Alexander Ross gave “a misleading impression of the arrangements in place at the home in respect of maintenance and inspection”.

Sheriff Principal Lockhart said the fire started when an exposed wire touched the metal of the fuse box, releasing a spark.

If the system had been inspected and tested in accordance with the IEE regulations, the lack of insulation on the wire “would have been identified and rectified,” said the Sheriff Principal. “In that event, the fire would not have occurred and the deaths might have been avoided.”

He noted that in the period between the fire and the end of the 141-day inquiry there had already been “developments of a significant nature”, which reduced the need for additional recommendations.

Rosepark has been fitted with a fire panel that automatically dials the fire brigade as soon as the alarm sounds, while swing-free closures have been fitted to bedrooms so that they shut whenever a smoke detector is set off.

There are also monthly fire drills, quarterly electrical inspections and all staff must take a fire warden’s course.

However, the Sheriff Principal called for care home staff to have their duties more clearly explained, and urged Scottish ministers to formalise the relationship between the various regulatory bodies -- the Fire and Rescue Authorities, the Health & Safety Executive, and SCSWIS (Social Care and Social Work Improvement Scotland), which took over from the Care Commission on April 1 -- to prevent a repeat of the confusion by inspectors seen at Rosepark.

Brian Sweeney, chief officer of Strathclyde Fire and Rescue, said: “The nine-minute delay in calling us was crucial and the recommendations and observations of the sheriff regarding the Care Commission, the Health Board, the owners and the staff must now be the focus of attention.”

A spokesman for NHS Lanarkshire, responsible for inspection until 2002, said: “We will need time to study [the Determination] to identify if there are any areas where we could improve practice for the NHS premises we are responsible for in Lanarkshire.”

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