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April 21, 2011

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Rosepark care home fire deaths avoidable says inquiry report

Some or all of the 14 deaths in the Rosepark care home fire in 2004 might have been avoided if a proper risk assessment had been carried out and the findings acted on, says a Fatal Accident Inquiry report published yesterday.

The fire itself was caused by an earth fault at the back of an electrical distribution box in a storage cupboard. But the Fatal Accident Inquiry (FAI) determination by Sheriff Principal Brian Lockhart lists a catalogue of precautions that, if taken, might have avoided the deaths.

Central to these was the lack of a suitable and sufficient fire risk assessment. The document purporting to be a risk assessment “critically failed to identify the residents of the home 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,” says the report.

The report goes on to say that had a suitable and sufficient fire risk assessment been made, many of the “reasonable precautions” which might have avoided the fire and some or all of the deaths, would have been identified and could have been acted on. These include:

  • The storage cupboard to have been kept securely closed, to have been fitted with fire resisting doors, and not to have contained combustible materials inside
  • All bedroom doors to have had door closers and smoke seals fitted to them
  • The sub-division of a corridor into two compartments
  • The installation of fire dampers according to building regulations
  • The provision of clear information at the fire alarm panel (in particular a diagrammatic zone plan) to allow staff to quickly identify the location of the device that had been activated
  • Adequate staff training including fire drills
  • Early and sufficient response by the fire and rescue service

The determination also goes on to list defects in the systems of working at the care home which contributed to the deaths. These include:

  • The maintenance of the electrical installation at the care home
  • Inadequate fire safety training and drills
  • The management of fire safety which was “systematically and seriously defective” at Rosepark
  • The management of the construction process at Rosepark
  • The interaction between Rosepark and Lanarkshire Health Board

The Sheriff Principal’s report makes various conclusions and recommendations, acknowledging that there have been “very substantial developments” in fire safety in care homes since the Rosepark tragedy. In particular, he said the Scottish government publication Practical Fire Safety Guidance for Care Homes “provides the clearest guidance for those who seek to administer and regulate care homes in Scotland,” and “represents a significant and appropriate response by Scottish ministers to the issues which have been raised to date by Rosepark.”

Scottish building regulations concerning care homes have also been amended since the fire.

The determination also commended a report and set of recommendations made by fire safety consultant, Colin Todd, who gave evidence to the inquiry. Mr Todd’s report covers issues including the use of addressable detection and alarm systems; the provision of a diagrammatic alarm zone plan; the minimum number of staff needed for evacuation; the retro-fitting of sprinklers; the value of third party certification; and the importance of selecting competent fire risk assessors. As an interim measure, the Scottish government has recently added references to the value of third party certification, and has referred to the currently available fire risk assessor registers.

In 2007 and 2008, attempts to prosecute the care home’s owners – Thomas and Anne Balmer and their son Alan – for alleged fire safety breaches failed. In his conclusion to the FAI report, the Sheriff Principal said:

“A Fatal Accident Inquiry is an exercise in applying the wisdom of hindsight. The purpose of the conclusions drawn is to assist those legitimately interested in the circumstances of the death to look to the future in order that they, armed with hindsight, the evidence led at the inquiry, and the determination of the inquiry, may be persuaded to take steps to prevent any recurrence of such a death in the future.”

Read the full FAI report

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