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January 23, 2012

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Lessons from the Rosepark care home tragedy

The Rosepark care home fire in 2004 in which 14 people died was the worst fire in a care home in the UK. The investigation, research, findings and lessons to be learned from the tragedy were presented at a special BRE conference last month, as Martin Shipp discusses.

During the night of 31 January 2004, the fire alarm in Rosepark Care Home actuated. The staff on duty had difficulty locating the fire and the fire brigade were called.

Most of the elderly residents were evacuated from the building. The fire and rescue service crew in breathing apparatus found two corridors of the building heavily smoke logged, but only very small patches of fire, which they extinguished. They examined the bedrooms off these two corridors and identified a number of fatally injured victims, and some who they were able to rescue. Of those rescued, some later died in hospital. In total, fourteen elderly people died in the incident. The fire was the worst fire in a care home in the UK.

A number of investigations and reviews were immediately initiated, involving Strathclyde Police, Strathclyde Fire and Rescue Service, the Crown Office and Procurator Fiscal Service, Health and Safety Executive (HSE), and the Scottish Executive (via Scottish Building Standards Agency). A detailed examination of the cause of the fire was carried out at the Health and Safety Laboratory, an agency of the HSE.

After some time spent on legal processes, a Fatal Accident Inquiry was started in November 2009 and concluded in August 2010 after 141 days of evidence. It is considered to be the longest Fatal Accident Inquiry in Scottish history. The Sheriff Principals’ Determination was published in April 2011.

The conference
The completion of the Fatal Accident Inquiry means that it is now possible to make the findings of the investigations and research available to a wider audience.

Following an event in August 2011 hosted by Strathclyde Fire & Rescue Service which addressed the lessons learnt from the Rosepark tragedy, BRE held a conference on 6 December, with the approval of the Crown Office and Procurator Fiscal Service and the Scottish Building Standards Agency. The conference aimed to present the research and to ensure that the important lessons from Rosepark were made available to the wider fire safety, care home, and healthcare communities. Contributors were asked to describe the various items of research carried out in connection with Rosepark; its methodology and process, its findings, and how these findings might be used to assist managing fire safety in these types of premises in the future.

The conference was attended by over 150 delegates and contributors and was chaired by Phil Buttery, BRE Global director, who has special responsibility for the healthcare sector.

The conference started with a presentation by Colin Hird of the Scottish Building Standards Agency, who gave an overview of the Rosepark care home fire. Colin discussed the issues that made the fire so important and the response of Scottish ministers. The Scottish Executive had needed to fully understand why the fire occurred and distil lessons learned, for example, about causes, equipment or human failures. Research was needed to inform policy formulation in relation to care home fire regulations in existing premises, assist preparation of guidance offered under the Building Regulations and the Technical Standards, and contribute to the safe management of such premises. Also of importance were issues regarding the potential value of sprinklers in such premises.

This was followed by Alan Smith of Strathclyde Fire and Rescue Service, who briefly described the fire service response to the Rosepark care home fire. He provided background to how Strathclyde Fire and Rescue dealt with the incident with an incident timeline.

Carol Ann Brown of Strathclyde Police then summarised the investigation into the Rosepark care home fire and the police role. The police had had primacy with the investigation, on behalf of the Procurator Fiscal, and had played a significant role in supporting the research carried out by the other agencies.

A presentation on the investigation into the cause of the fire was given by Stuart Mortimore of Burgoynes. Stuart had originally become involved in the incident to examine the fire alarm system. However, he then assisted with the investigation into the origin and cause of the fire, and he described how the most likely cause, faulty electrical equipment, had been identified.

This was followed by Stuart Jagger, of the Health and Safety Laboratory, who described the investigation into the development of the fire by HSL. HSL had constructed a mock-up of the cupboard where the fire had started and carried out a large number of tests to seek to replicate the ignition process.

Martin Shipp of BRE Global then outlined the full-scale reconstructions of the fire, commissioned by the Scottish Building Standards Agency and carried out by BRE. This required the construction of a full-scale test rig representing two corridors in Rosepark, and all of the bedrooms off those corridors. The rig was extensively equipped with thermocouples and other instruments. Three main tests had been carried out, the first being a reconstruction of the actual incident. The second test replicated the first but with a sprinkler system throughout. The third test replicated the first but with closed fire doors fitted to the bedrooms. Later, BRE was commissioned by the Crown Office and Procurator Fiscal Service to carry out some other experimental trials to examine the potential for smoke spread through the ventilation ducting in the false ceiling in the corridors at Rosepark, and to examine the fire performance of ordinary (non-fire resisting) bedroom doors.

David Purser of Hartford Environmental Research spoke about the toxicological analysis of the Rosepark care home fire. The toxicological data from the BRE reconstruction had been used to calculate survival times using the Fractional Effective Dose methodology, and these data had been compared with the carboxyhaemoglobin levels found in the blood of the fatalities. There had been a good match for those victims in rooms off the main corridor, but a poorer fit for those in bedrooms off the adjoining corridor and who should have received some protection from the fire by the corridor fire door. These differences could largely be accounted for by smoke movement through the ventilation ducting.

Fire safety management
Colin Todd of CS Todd & Associates then presented on the fire safety management and fire risk at Rosepark. Colin had been commissioned by the Crown Office and Procurator Fiscal Service to review the management of the home and the management of the incident. He summarised the significant findings and recommendations in the Sheriff’s determination.

Colin Hird (Scottish Building Standards Agency) completed the day with a presentation on fire safety in care homes after Rosepark, where he discussed how the Scottish Government had responded and how guidance documents had been or were being revised to reflect many of the key findings from the incident.

There were a number of questions from the floor, and consequential discussion. Two issues were of particular concern. Firstly, there remained some uncertainty regarding the cause of the fire and how alternative causes had been eliminated. This was discussed and it was explained further how the cause had been identified. Secondly, the Sheriff had advised that the fire brigade should be called whenever a fire alarm actuated in a care home. However, this appeared to be in conflict to the practice in some parts of the UK where fire and rescue authorities will charge care homes (or any other premises) a fee if the call-out is the result of a false alarm. Fire officers present at the conference admitted that this was a problem in some parts of the UK, but not all.

Conclusions
BRE had a large number of feedback forms returned and it was evident that the event was extremely well received and considered very helpful by both the fire community and the care home community. With the approval of the Crown Office and Procurator Fiscal Service, BRE has made the PowerPoint presentations available on the BRE website. It is hoped that the event might be re-run early in 2012 in Scotland.

Martin Shipp is technical development director, fire safety at BRE Global.

Acknowledgments
Thanks go to all the presenters and participants and, at BRE, Phil Buttery, Antonia Crawford, David Crowder, Helen Ball, and, especially, Laura Williams, the conference organiser.

Further reading

Determination by Sheriff Principal Brian A Lockhart

Appendices to the Determination by the Sheriff Principal

Rosepark Care Home: an Examination of the Facts – Strathclyde Fire and Rescue Service

BRE research for the Scottish Building Standards Agency

Fire tests carried out by BRE for the Crown Office and Procurator Fiscal Service

BRE intends to publish a summary of the BRE work for the Scottish Building Standards Agency and the Crown Office and Procurator Fiscal Service in the near future.

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