Rosepark care home fire deaths could have been prevented

Fourteen elderly residents were killed and four other people injured in the 2004 blaze.

The fire, which broke out overnight, started in a cupboard and quickly spread through Rosepark care home

A fatal Accident Inquiry (FAI) has concluded that fire safety plans were “systematically and seriously defective”.

Sheriff principal Brian Lockhart has published his findings following an inquiry lasting 141 days.

He found that “some or all” of the deaths could have been prevented if Rosepark home, run by Anne and Thomas Balmer, had a “suitable and sufficient” fire safety plan.

Mr Lockhart concluded: “The management of fire safety at Rosepark was systematically and seriously defective. The deficiencies in the management of fire safety at Rosepark contributed to the deaths.”

Poor risk assesment

He said the “critical failing” was not to identify residents at the home as being at risk in the event of a fire, as well as failing to consider the “worst-case scenario” of a fire breaking out at night.

A further “serious deficiency” was found in the “limited attention” given to how residents would escape from the home in the event of a fire.

There are no circumstances in which one would condone a procedure that involved sending members of staff to look and see if there was a fire before calling the fire brigade. Sheriff principal Brian Lockhart

The sheriff said an adequate fire plan would have revealed the problems which eventually led to the deaths, such as staff not being properly trained in fire safety and the presence of an electrical distribution board in a cupboard which opened to a “critical escape route” alongside flammable materials.

He also highlighted “inadequate arrangements” for calling the fire brigade, a lack of fire dampeners and too many people being housed in one corridor in order to evacuate them effectively.

He said the risk assessment was “obtained in good faith” but contained a “serious error”.

Delay in dialing 999

The inquiry also concluded that the lives of four of the Rosepark residents – Isabella MacLachlan, Margaret Gow, Isabella MacLeod and Robina Burns – could have been saved if the fire brigade was called as soon as the fire alarm sounded.

The four women died later in hospital of conditions related to the smoke and gas they inhaled.

Rosepark’s practice meant a member of staff had to find the source of the blaze before dialling 999. Staff waited nine minutes before they contacted the fire brigade, the inquiry heard.

An extra delay, of just over four minutes, was added when the fire brigade went to the wrong entrance to the home.

The sheriff said: “Time is of the essence because even a small fire is capable of generating large volumes of smoke which could result in casualties.”

It was “absolutely essential” that the fire brigade was called as soon as the alarm sounded.

He said there were “no circumstances in which one would condone a procedure that involved sending members of staff to look and see if there was a fire before calling the fire brigade”.

Lanarkshire Health Board was also criticised for its “deficient way of working”.

He said problems with Rosepark’s practices, including leaving residents’ bedroom doors open at night, not calling the fire brigade immediately and failures in fire drill training for staff, should have been uncovered by the health board during its inspection.