Colin Todd Managing Director C. S. Todd & Associates Ltd
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1 Colin Todd Managing Director C. S. Todd & Associates Ltd CS TA
2 ROSEPARK CARE HOME, UDDINGSTON Corridor Cor rid or Rosepark care home
3 Fire resisting doors/selfclosing doors Size of subcompartment KEY ISSUES Fire Risk Assessment
4 THE CROWN THE BALMERS STRATHCLYDE F&RS NHS LANARKSHIRE CARE COMMISSION NORTH LANARKSHIRE COUNCIL SCOTTISH MINISTERS GEORGE MUIR ALEXANDER ROSS SARAH MEANEY ISOBEL QUEEN BRIAN NORTON IRENE RICHMOND YVONNE CARLISLE JOSEPH CLARK JAMES REID
5 DOES NOT ESTABLISH BLAME, FAULT OR CIVIL/CRIMINAL LIABILITY ESTABLISHES (ON BALANCE OF PROBABILITY): - WHERE/WHEN DEATHS AND ACCIDENT TOOK PLACE - REASONABLE PRECAUTIONS WHEREBY DEATHS AND ACCIDENT MIGHT HAVE BEEN AVOIDED - ANY DEFECTS IN ANY SYSTEM OF WORKING CAUSING/ CONTRIBUTING TO ACCIDENT OR DEATHS - ANY OTHER FACTS RELEVANT TO CIRCUMSTANCES OF DEATHS REASONABLE PRECAUTIONS APPLIES WISDOM OF HINDSIGHT
6 CAUSES OF DEATHS INHALATION OF SMOKE AND THE FIRE GASES CAUSE OF ACCIDENT EARTH FAULT WHERE CABLE PASSED THROUGH KNOCKOUT IN DIS BOARD LIVE CONDUCTOR CAME INTO CONTACT WITH METAL EDGE OF KNOCKOUT ARC GENERATED CABLE SHEATH STRIPPED BACK TOO FAR KNOCKOUT HAD NO GROMMET PVC INSULATION ABRADED SPARKS IGNITED EITHER COMBUSTIBLES OR FLAMMABLE CLOUD
7 REASONABLE PRECAUTIONS RP1: RP2: GROMMETAT KNOCKOUT AND CABLE SHEATH NOT STRIPPED BACK (FIRE AND ALL DEATHS) INSPECTION AND TESTING OF ELECTRICAL INSTALLATION (FIRE AND ALL DEATHS) - ON COMPLETION - WHEN CABLE ADDED - WHEN INSTALLATION 5 AND 10 YEARS OLD
8 REASONABLE PRECAUTIONS RP3: RP3.1: RP3.1.1: RP3.1.2: PROTECTION OF MEANS OF ESCAPE CUPBOARD DOORS CUPBOARD DOORS LOCKED SHUT OR AT LEAST SECURELY CLOSED (SOME OR ALL DEATHS) FIRE DOORS TO CUPBOARD (SOME OR ALL DEATHS IF SECURELY CLOSED)
9 REASONABLE PRECAUTIONS RP3.2: CLOSED BEDROOM DOORS - ONLY TWO BEDROOM DOORS CLOSED - WOULD HAVE BEEN RP TO FIT DOOR RELEASE MECHANISMS - DEVICES AVAILABLE AT ALL RELEVANT TIMES - RELIANCE ON STAFF WOULD NEED ATTENTION TO TRAINING/DRILLS/ STAFF NUMBERS - SUITABLE AND SUFFICIENT FRA WOULD HAVE IDENTIFIED NEED - CLOSED DOORS WOULD HAVE STARVED FIRE
10 REASONABLE PRECAUTIONS RP3.2 (cont d): RP3.3 RP3.4 EFFECTS ON OUTCOME - IMPROVED PROSPECTS FOR TWO RESIDENTS WITH CLOSED DOORS - OTHER DEATHS IN THAT CORRIDOR MIGHT HAVE BEEN AVOIDED - TWO RESIDENTS IN NEXT CORRIDOR MIGHT HAVE SURVIVED SMOKE SEALS ON BEDROOM DOORS (TWO DEATHS) MINIMISE COMBUSTIBLES IN CUPBOARD; PARTICULARLY NO AEROSOLS (TWO DEATHS PLUS ALL OTHERS IF PROMPT STAFF ACTION AND SECURED DOORS)
11 REASONABLE PRECAUTIONS RP3.5: SUBDIVIDE CORRIDOR 4 (7 DEATHS) - OBVIOUS TO FIRE SAFETY PROFESSIONAL - WOULD HAVE BEEN IDENTIFIED BY SUITABLE AND SUFFICIENT FRA ALTERNATIVES - INTERIM MEASURE -TAKE FEWER RESIDENTS - MOVED HEAVILY DEPENDENT RESIDENTS ELSEWHERE - SPRINKLER SYSTEM - ADDITIONAL STAFF AT NIGHT
12 REASONABLE PRECAUTIONS RP3.6: RP4: RP4.1 FIRE DAMPERS (2 DEATHS FROM SMOKE INHALATION PLUS DIFFERENT STAFF/FIRE SERVICE ACTIONS SO SOME OF OTHER DEATHS) PROMPT AND EFFECTIVE ACTION BY STAFF CLEAR INFO AT FIRE PANEL, PARTICULARLY ZONE PLAN (SOME OR ALL DEATHS)
13 REASONABLE PRECAUTIONS RP4.2: RP4.3: TRAINING AND DRILLS (SOME OR ALL DEATHS) INSTRUCTION OF ISOBEL QUEEN IN NEW FIRE PANEL (SOME OR ALL DEATHS) RP5: EARLY INVOLVEMENT OF FIRE BRIGADE (4 DEATHS NOT OTHERS) RP5.1: IMMEDIATE CALL/EMERGENCY PROCEDURE/ARC CONNECTION (9 MIN DELAY)
14 REASONABLE PRECAUTIONS RP5.2: RP5.3: RP5.4: RP5.5: INFO FOR 999 CALL IN MATRON S OFFICE ACCESS ADDRESS AT TOP OF CALLOUT SLIP CLASSIFICATION OF ROSEPARK AS SPECIAL RISK, SO ANNUAL 1(i)(d) EACH WATCH FIRST APPLIANCE TO HAVE ATTENDED ROSEPARK AVENUE (4 MIN 25 SEC DELAY)
15 REASONABLE PRECAUTIONS RP6: SUITABLE AND SUFFICIENT FRA (FIRE AND SOME OR ALL DEATHS) - FRA BY JAMES REID NOT SUITABLE AND SUFFICIENT - NO ACTION BY MANAGEMENT IN ANY CASE - FAILED TO CONSIDER RESIDENTS - FAILED TO ADDRESS MANY ISSUES
16 REASONABLE PRECAUTIONS RP7: EARLY AND SUFFICIENT RESOURCING OF INCIDENT BY FIRE BRIGADE (ONE DEATH) - SHERIFF ACKNOWLEDGES FIRE UNIQUE IN 14 WAYS NOT KNOWN TO OIC NOW, WITH BENEFIT OF HINDSIGHT: RP7.1: RP7.2: OIC TO EXAMINE FIRE PANEL/ZONE CARD TO VERIFY STAFF INFO OIC TO TREAT UPPER FLOOR RESIDENTS AS UNACCOUNTED FOR
17 REASONABLE PRECAUTIONS RP7.3: RP7.6: OIC TO CONFIRM WHETHER BEDROOM DOORS OPEN OR CLOSED MAKE PUMPS 6 MESSAGE 35 MINS EARLIER WHEN PERSONS REPORTED SENT
18 DEFECTS IN ANY SYSTEM OF WORKING DS1: DS2: DS3: DS3.1: MAINTENANCE OF ELECTRICAL INSTALLATION (FIRE AND ALL DEATHS) FIRE SAFETY TRAINING AND DRILLS (SOME OR ALL DEATHS) MANAGEMENT OF FIRE SAFETY MANAGEMENT OF FIRE SAFETY WAS SYSTEMATICALLY AND SERIOUSLY DEFECTIVE (SOME OR ALL DEATHS)
19 DEFECTS IN ANY SYSTEM OF WORKING DS3.2: DS4: ANUMBER OF KEY CIRCUMSTANCES WOULD HAVE BEEN DIFFERENT (SOME OR ALL DEATHS) MANAGEMENT OF CONSTRUCTION PROCESS [FAILURE TO IDENTIFY ABSENCE OF ELEC INSPECTION/TESTING CONTRIBUTED TO FIRE AND DEATHS]
20 DEFECTS IN ANY SYSTEM OF WORKING DS5: INTERACTION BETWEEN ROSEPARK AND LANARKSHIRE HEALTH BOARD (SOME OR ALL DEATHS) - INADEQUATE APPRECIATION OF STATUTORY RESPONSIBILITIES - NO SETTING OF STANDARDS FOR SUITABLE AND SUFFICIENT FIRE PRECAUTIONS - HEALTH BOARD DID NOT RECOGNIZE THAT IT SHOULD HAVE EXAMINED FIRE PRECAUTIONS - FUNDAMENTAL MISUNDERSTANDING OF ROLE OF STRATHCLYDE F&RS
21 OTHER RELEVANT FACTS OF1: OF2: STRATHCLYDE F&RS WERE NOT INSPECTING CARE HOMES THE CARE COMMISION AND ITS INTERACTION WITH ROSEPARK NATIONAL CARE STANDARDS RESULTED IN WEAKER REGIME OF INSPECTION - IN 2003 FIRE SAFETY AT ROSEPARK NOT SCRUTINISED IN ANY DEPTH - WAY IN WHICH FIRE PRECAUTIONS EXAMINED UNLIKELY TO UNCOVER DEFECTS IN POLICIES/PROCEDURES - FOCUS ON CARE, RATHER THAN SAFETY - NO BASIS FOR FINDINGS THAT APPROPRIATE POLICIES/PROCEDURES/RECORDS/STAFF KNOWLEDGE
22 OTHER RELEVANT FACTS OF3: OF4: OF5: OF6: CARE COMMISSION/STRATHCLYDE F&RS UNDERSTANDING OF RESPECTIVE ROLES COMPLETION CERTIFICATE ISSUED WHEN SERIOUS COMPLIANCE FAILURE (DAMPERS) NO EXTERNAL CHECK OF DOCUMENTATION FOR TESTING/INSPECTION OF ELEC AND VENTILATION INSTALLATIONS NO STATUTORY REQUIREMENT FOR QUALS OF FIRE RISK ASSESSORS OF CARE HOMES
23 OTHER RELEVANT FACTS OF7: DEVELOPMENTS SINCE THE FIRE OF7.1: ADVISORY VISITS AFTER FIRE OF7.2: MoU BETWEEN CARE COMMISSION AND THE 8 F&RS OF7.3: OPERATIONAL CHANGES AND DEVELOPMENTS IN STRATHCLYDE F&RS OF7.4: THE FIRE (SCOTLAND) ACT OF8: OF9: CHANGES MADE TO BUILDING REGULATIONS CHANGES AT ROSEPARK ITSELF
24 OTHER RELEVANT FACTS OF10: FUTURE REGULATORY DEVELOPMENTS - SCSWIS (LOSE PRIVATE HOSPITALS) OF11: SHERIFF COMMENDS COLIN TODD S RECOMMENDATIONS TO SCOTTISH MINISTERS FOR CAREFUL CONSIDERATION
25 SHERIFF S CONCLUSIONS 1. BALMER CARE HOMES LTD HAVE TAKEN STEPS TO ERADICATE DEFICIENCIES. 2. THE HEALTH BOARD S APPROACH WAS DEFECTIVE. THE CARE COMMISSION S APPROACH ADOPTED THE TENOR OF THE LEGISLATION. F&RS NOW CARRY OUT INSPECTIONS. 3. STRATHCLYDE F&RS HAVE IMPLEMENTED CHANGES. 4. SHERIFF MAKES PROPOSALS RE ROLE OF ARCHITECT AND BUILDING CONTROL. 5. THERE SHOULD BE CHECKING OF DOCUMENTATION RE INSPEC/TEST OF ELEC/VENT SYSTEMS. CONSIDERATION SHOULD BE GIVEN TO CERT OF COMPARTMENTATION AT REGISTRATION.
26 SHERIFF S CONCLUSIONS 6. STAFF TRAINING RE DUTIES IS REQUIRED. DUTIES SHOULD BE AUDITED. 7. THERE SHOULD BE FORMAL FOOTING FOR RELATIONSHIP BETWEEN SCSWIS, F&RS AND HSE. 8. SHERIFF COMMENDS COLIN TODD S REPORT TO SCOTTISH MINISTERS. 9. RESIDENTS/POTENTIAL RESIDENTS SHOULD BE REASSURED. SCOTTISH MINISTERS WILL CONSIDER WHETHER GUIDANCE REQUIRES FURTHER REVISION IN VIEW OF DETERMINATION AND IN PARTICULAR RECS OF COLIN TODD.
27 1. INSPECTION AND TESTING OF ELECTRICAL INSTALLATIONS 2. ADDRESSABLE FIRE ALARM SYSTEMS 3. ZONE PLANS 4. STAFFING NUMBERS 5. SPRINKLER SYSTEMS 6. PROTECTED CORRIDORS 7. SELF CLOSING DEVICES 8. ARC CONNECTIONS 9. STAFF ALARMS
28 10. THIRD PARTY CERTIFICATION 11. STAFF TRAINING 12. ROUTINE INSPECTIONS 13. PLANS FOR FRS USE 14. PRINCIPLE OF CARE 15. CALL CHALLENGING 16. FAMILIARIZATION VISITS 17. COMPETENCE OF RISK ASSESSORS 18. INFORMATION ON FIRE STRATEGY
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