Rose Park: Catalogue of errors that led to disaster

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.”