Introduction This report is a summary of the findings from a study conducted into the Five London Hospital Fires by Philip Gibbs of London Fire Brigade. The purpose of this report is to: Highlight fire safety issues from major hospital fires Apply the lessons to future audits 2016-4 1
1. Great Ormond Street Hospital 29 th September 2008: 6 pumps: Great Ormond Street, London, WC1N 3JH. Audit history Audit carried out three months before the incident. Broadly compliant. A comprehensive fire risk assessment had been carried out by a consultant and management procedures were in place to address the significant findings. The building wasn t perfect, but there was an action list which appeared to cover all issues. Incident A faulty television in a day room in the Cardiac Wing caused a fire which led to a small oxygen cylinder exploding. The explosion was caused by over pressure of a full 2 litre BOC oxygen cylinder containing 460 litres of oxygen at 230 bar. The cylinder was not fitted with a pressure release valve (no requirement). The cylinder was on a tray at the base of a pram. The pram was under the TV on the wall. Several soft toys were stored around pram. The handle of the cylinder was not burnt, indicating that the cylinder was not engulfed in flames. The TV was the cause of the fire. Flames were seen inside the TV. The fire spread to the toys and the pram and heated the cylinder. The explosion was due to over pressure and not a chemical reaction or deflagration. From activation of the detector in room of origin to the explosion was 10 minutes. Before the explosion a breathing apparatus crew of four attempted to fight the fire with nearby extinguishers and then a hose reel. This attempt failed as the fire was growing too quickly. At this stage they would not have been aware of the location of the cylinder due to the amount of smoke being generated. The entire crew retreated behind double fire doors in order to attach a hose to the Dry Riser. It was at this point that the explosion occurred and the doors were blown off their hinges. All four crew members were taken to another hospital for treatment for minor injuries. If they had been the other side of the fire doors at the time of the explosion it is unlikely that they would have survived. Fire spread None. Contained to room of origin. The explosion extinguished the fire. Result of fire Evacuation of building and parts of other buildings. No-one other than firefighters injured. Day room destroyed, plus damage to adjoining rooms and some external damage from flying debris. Water damage to lower floors. LFB Action Post fire audit confirmed that lessons had been learned and were being addressed. Building was generally well managed and evacuation procedure worked efficiently. No further action was taken. Key lessons Isolate electrical faults immediately Activate alarm on smell of smoke Manage cylinders 2016-4 2
1A Great Ormond Street Hospital 2016-4 3
1B Great Ormond Street Hospital 2016-4 4
2. University College Hospital 25 th July 2008: 20 pumps: Grafton Way, London, WC1E 6DB Audit history None. Incident The building concerned was the Rosenheim Day Care Hospital run by University College London Hospitals NHS Foundation Trust. The incident started at about 2am and there was no life risk in the Rosenheim and no other evacuations were necessary. The fire started in a basement tunnel. It was probably arson but this has not been proved. The tunnel runs below the street and connects the Rosenheim to other UCLH buildings. The tunnel is used for access between buildings and contains IT network cabling and a pneumatic tube system for the transfer of samples. A storeroom, which contained dry consumables, had been added to one side of the tunnel under the Rosenheim. The construction was fire rated and intumescent collars had been fitted around the plastic pneumatic tubes where they penetrated the walls of the storeroom. The collars expand when heated and crush the tube they surround. Unfortunately the collars had not been fitted properly. They were not secured. The two holes in the walls in which they sat were not fire stopped and the collars were rated at a higher temperature then the plastic tubes. The result of these failures was that the plastic tubes melted before the material in the collars activated, and the collars fell out of the holes they were supposed to plug. The fire was mainly contained around the storeroom. However, when the first crews arrived there was smoke issuing from various orifices at street level. Many detectors in different locations had activated, so the exact location was difficult to determine. Being a basement fire meant that temperatures were excessive and the immediate area was smoke logged. Fire spread None. The fire doors in the tunnel prevented fire spread but smoke did penetrate the nearest stair in the Rosenheim and affected other areas. Some of this was due to the need to vent the Basement. Result of fire The storeroom was destroyed and the immediate area damaged. The result of this relatively small fire caused considerable cost and disruption for weeks afterwards, due to the damage to the pneumatic tube system and IT network. LFB Action The Rosenheim had been risk assessed, but not the tunnel below. The Chief Executive of the Trust was interviewed under caution and asked if he could explain why the aforementioned deficiencies were not addressed before the fire. No further enforcement action was taken. A post fire audit revealed that procedures had improved and the tunnel was refurbished to a very high standard and sprinklers were fitted. Key lessons Arson control Fire-stopping of services Use qualified/accredited installers Storage in corridors Ensure all areas are risk assessed 2016-4 5
2. University College Hospital 2016-4 6
3. Northwick Park Hospital 11 th February 2009: 8 pumps: Watford Road, Harrow, London, HA1 3UJ. FSO Audit history None. Incident A fire was contained in an electrical plant room on the ground floor of one wing of the main ward block of Northwick Park Hospital. The building is eleven stories including basement. Steel frame construction with brick and block walls. Concrete ceiling and roof. Built in about 1969. Smoke spread into a long service corridor outside the plant room and from there it penetrated parts of the upper floors and funnelled up the side of the building. Fire caused by a fault in a low voltage stabiliser. Fire spread No, but considerable smoke spread throughout the building. Result of fire Partial evacuation of hospital was carried out and no-one was injured. Considerable damage to the plant room. Severe disruption was caused to various services in the building for weeks following the incident. LFB Action Following the fire it was found that there was a lack of fire stopping to pipe work cabling through partition walls in the room of origin. In addition, there was a lack of compartmentation in the risers between floors. There was also an excessive amount of trolleys containing dirty laundry and other combustible items in the service corridor outside the plant room. This hampered firefighting operations and could have assisted in fire spread. An Enforcement Notice was issued. Considerable improvements were made to the building and the management of the building since this incident. Key lessons Activate alarm on smell of smoke Plant room used for storage Fire-stopping of services Storage in corridors 2016-4 7
3. Northwick Park Hospital 2016-4 8
4. Chase Farm Hospital 15 th October 2008: 20 pumps: The Ridgeway, Enfield, Middlesex, EN2 8JL FSO Audit history None Incident Medium secure mental health unit built in 2003. Two and three floors and basement. Steel construction with brick lining. Pitched timber roof with slates. Wards on ground and 1 st floors. The rest of the building contained offices, laundry, kitchen, etc. There were two wards on the ground floor and two on the first floor, all to the rear of the building. The original design of the building included a roof garden on part of the structure. It was decided that this could not be secured, so to give patients on the first floor access to the garden an enclosed wooden staircase was added at the rear of the building. The patients on the ground floor were not allowed to mix with those on the first floor and they were segregated by fencing in the garden. Patients were allowed to smoke on the staircase and it was known that patients on the first floor could communicate with opposite gender patients on the ground floor using paper notes passed through the gaps in the barriers. The fire started on the staircase and the alarm was raised by staff and patients. The fire alarm panel also lit up like a Christmas tree. Fire spread Fire spread rapidly into the roof through the eaves and spread quickly along the whole of the roof and then down to lower floors. The whole building was evacuated. There was some lack of fire stopping and compartmentation in the roof void. Result of fire The building was partially destroyed. The shell remained standing, and was later rebuilt. Fire did not spread to the front of the building due to concrete partition walls. LFB Action None. It was decided not to take any enforcement action. Key lessons Control of smoking Roof compartmentation External fire spread Where to evacuate? 2016-4 9
4. Chase Farm Hospital 2016-4 10
5. Royal Marsden Hospital 2 nd January 2008: 25 pumps: Fulham Road, London, SW3 6JJ. FSO Audit history None. Incident This was probably the most dramatic of the five incidents because the Royal Marsden Hospital is a leading centre for cancer research and treatment and flames spread through the roof of the Chelsea wing. There appears to be comparisons with the Chase Farm Hospital fire, where fire spread rapidly through the roof of the building and then to other parts of the building. The cause of the fire was not confirmed, but could have been caused by hot works at the base of a vertical external shaft. Fire spread Probably through a vertical shaft attached to the building but external to it. This may have acted like a chimney and funnelled the fire to the roof void. Result of fire The Chelsea wing was evacuated, including operating theatres and the intensive care unit. 25 pumps attended involving about 125 firefighters. Damage was not as bad as originally thought and services began to resume the following week. No-one was injured as a direct result of the fire. Thousands of tissue and blood samples stored in fridges in the roof space were destroyed. LFB Action An Enforcement Notice was issued. This included deficiencies in the general management of the building and the fire separation within the building. Key lessons Roof compartmentation External fire spread? Where to evacuate? 2016-4 11
5. Royal Marsden Hospital 2016-4 12
Summary of causes of all 5 fires: GOSH: Electrical UCLH: Possible arson Northwick Park: Electrical Chase Farm: Possible arson/smoking Royal Marsden: Not confirmed Key lessons from the 5 fires: 1) However good management procedures are, assume the worst could happen. Ensure the emergency plan includes the complete evacuation of all parts of buildings. This includes training staff in vertical evacuation techniques and providing the appropriate equipment. Plans should be tested as far as possible with some form of fire drill, which includes vertical evacuation. Consider how to continue patient treatment after evacuation. 2) Pay particular attention to compartmentation, fire load and detection in roof voids. Also consider the likelihood of fire spread into a roof space from the outside. 3) Anything electrical is a fire hazard. 4) Smoking outside healthcare premises can cause fires which spread to the inside. 5) Hospitals are tempting targets for arsonists. 2016-4 13