FIRE SAFETY - 08.06.2011

Management errors linked to care home deaths

Recap

Rosepark Care Home in Lanarkshire suffered a serious fire in 2004 which caused the deaths of 14 elderly residents(yr.9, iss.17, pg.2, see The next step). A recent Fatal Accident Inquiry (FAI) report identified a catalogue of errors which included “systematic and seriously defective” fire safety management arrangements. What were they and what can you learn from them?

Delayed call

One of the most significant errors made was a delay in phoning the Fire and Rescue Service (FRS). The FAI concluded that four of the residents could have been saved if the call had been made sooner. The reason for the wait was that members of staff attempted to locate the source of the fire before dialling 999. After nine minutes, having failed to locate it, they decided to phone the emergency services anyway.

Tip 1. Staff should be instructed to phone the FRS on the sounding of the alarm, unless they know for certain that it’s a false alarm.

Tip 2. Another bad practice operating at the home was to silence and reset the alarm, then wait to see whether it was triggered again. A building should always be evacuated when the alarm sounds and any checking to find the cause should take place once the premises is clear.

Why couldn’t they find the fire?

The cause of the excessive delay was due to poor information provided to staff. The building was two storeys but due to being constructed on a slope, both floors had an exit at ground level. The staff tended to call the floors “upstairs” and “downstairs” but the zone descriptor on the panel used “ground floor” and “lower ground floor”. This simple naming problem caused so much confusion that in the heat of the moment, the staff couldn’t understand which part of the building was affected.

Tip 1. Make sure you have a zone plan next to your panel.

Tip 2. If you have an addressable system (one that gives detailed location information) check that the details provided can be easily understood. Often these plans are drawn up by alarm engineers without input from staff and this causes inaccuracies.

Training

One way in which the home could have overcome the problem of the zone confusion would have been through staff training. But training was limited to viewing a generic fire safety video and completing a short test at the end. There was no specific training in the fire procedures at Rosepark itself - and the omission even extended to the nurse in charge. She had been given no training in her role, had not been shown the fire procedures and was unfamiliar with the fire panel.

Tip. Training videos have their place but should be supported by specific instruction in your fire procedures. Make sure that any member of staff who has a particular role is familiar with their responsibilities as defined in your fire safety policy (see The next step).

For a previous article on Rosepark (HS 09.19.04A) and a sample fire safety policy (HS 09.19.04B), visit http://healthandsafety.indicator.co.uk.