Rosepark care home fire inquiry says deaths were avoidable

Rosepark care home fire inquiry says deaths were avoidable

3 May 2011
A Fatal Accident Inquiry report published last week stated that at least some of the deaths at the 2004 Rosepark care home fire could have been avoided had there been a proper fire risk assessment and the findings acted upon.

The cause of the fire was an earth fault in an electrical distribution box located in a storage cupboard. However, Brian Lockhart, the Sheriff Principal listed in the Fatal Accident Inquiry precautions that could have negated the risks, had they been carried out.

The main precaution lacking was a fire risk assessment that was suitable or carried out in enough detail. A risk assessment was carried out, however, the report states that the resulting document “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.”

A suitable and sufficient fire risk assessment would have identified many reasonable precautions that might have been carried out, avoiding the fire itself and at least some of the deaths that occurred.

The reasonable precautions stated include keeping the storage cupboard securely closed, fitting it with fire resisting doors, and not keeping fire combustible materials within. The report also advised that all bedroom doors should be provided with door closers and smoke seals; one corridor should be sub-divided into two compartments; fire dampers should be installed in accordance with building regulations; and clear information should be provided at the fire alarm panel, permitting staff to quickly locate the activated device. Staff should have adequate training, and an early and sufficient response should have been made by the fire and rescue service.

Moreover, the report lists defects in the system of working at Rosepark that also contributed to the disaster. The electrical installation was not sufficiently maintained, fire safety management was defective, the construction process was badly managed, and furthermore Rosepark and Lanarkshire Health Board did not interact effectively.

The report acknowledges that fire safety in care homes has been substantially developed since 2004, in particular clear guidance for administers of care homes in Scotland has been provided in the Scottish government’s publication entitled Practical Fire Safety Guidance for Care Homes. According to the Sherriff Principal’s report, this publication “represents a significant and appropriate response by Scottish ministers to the issues which have been raised to date by Rosepark.” Building regulations in Scotland have also been improved since the tragedy at Rosepark.

The Fatal Accident Inquiry had commendations to make regarding a report written by Colin Todd, a fire safety consultant who provided evidence to the enquiry. His report addresses issues such as the use of addressable detection and alarm systems and a diagrammatic alarm zone plan, the lowest number of staff required for evacuation, retro-fitting of sprinklers and the importance of selecting competent fire risk assessors.

Two attempts to prosecute the care home owners for alleged breaches of fire safety have been unsuccessful. In his report, the Sheriff Principal stated that the purpose of his conclusions was 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.”

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