Catalogue of failures behind Rosepark tragedy

THE deaths of 14 elderly people at a residential care home could have been prevented if its owners had put in place a "suitable" and "sufficient" fire plan, a fatal accident inquiry has ruled.

In a damning assessment of the "systematically and seriously defective" fire safety plans at Rosepark care home, and the inspection regime of health board officials, Sheriff Principal Brian Lockhart said "some or all" of the deaths would not have happened if proper measures had been in place.

The fire at the home in Uddingston, Lanarkshire, broke out in a cupboard overnight on 31 January, 2004, and ripped through the building. Ten residents died at the scene and four in hospital. The eldest was 98 and the youngest 75. Four other people were injured.

Publishing his findings after a 141-day fatal accident inquiry - the longest in Scottish history - Sheriff Lockhart highlighted a catalogue of errors that left staff unsure how to react when the fire alarm went off.

He 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. Management did not have a proper appreciation of its role and responsibilities in relation to issues of fire safety."

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 not considering the "worst-case scenario" of a fire breaking out at night.

A further "serious deficiency" was found in the "limited attention" given to how the residents could escape from the home. The sheriff said an adequate fire plan would have revealed the problems that eventually led to the deaths, such as staff not being properly trained in fire safety.

He also highlighted "inadequate arrangements" for calling the fire brigade, a lack of fire dampeners and too many people being housed in one corridor.

He said the risk assessment had been "obtained in good faith" but contained a "serious error".

The lives of four residents - Isabella MacLachlan, 93, Margaret Gow, 84, Isabella MacLeod, 75, and Robina Burns, 89 - could have been saved if the fire brigade had been called as soon as the fire alarm sounded, he said.

• 'It has been a strain, but at least families now know exactly what happened'

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

The other residents who died in the blaze were Dorothy McWee, 98, Tom Cook, 95, Julia McRoberts, 90, Annie Thompson and Helen Crawford, both 84, Margaret Lappin, 83, and May Mullen, Helen Milne, Anna Stirrat and Mary McKenner, all 82.

The inquiry, in Motherwell, was told the care home'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, and did not know where the blaze had broken out.

Sheriff Lockhart said: "In effect, they investigated all parts of the building other than where the fire actually was."

It was found that other than being shown a safety video, none of the staff on duty at Rosepark that night had had fire training or experience of a fire drill.

Isabel 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 and had not been told the fire procedures.

An extra delay of four minutes and 25 seconds was added when the fire brigade went to the wrong entrance to the home.

The sheriff said it was "absolutely essential" the fire brigade was called as soon as the alarm sounded. He also said Rosepark should have been given a special risk category by the fire service, meaning every watch at the local station would have visited it every year and been familiar with its layout.

The fire broke out in a cupboard because of an earth fault with a cable passing through an electrical distribution board.

The inquiry found evidence of a "defect" in the maintenance of the electrical system, which caused the fire. All the deaths would have been avoided if these had been installed and checked properly, the sheriff said.

NHS Lanarkshire was also criticised for its "deficient way of working".

The sheriff said problems at Rosepark - 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.

The board, responsible for inspecting the home between 1992 and 2002, when the Care Commission took over, had an "inadequate appreciation" of its responsibilities under the Nursing Homes Registration (Scotland) Regulations 1990.

The sheriff said the board had a "fundamental misunderstanding" of the role and responsibilities of Strathclyde Fire and Rescue and a "mistaken belief" fire services were responsible for inspecting the home for fire risks.Rosepark is owned by Thomas Balmer and his family, and a spokesman said: "Our legal team is studying the determination issued by Sheriff Principal Brian Lockhart. We have nothing further to add at present."

NHS Lanarkshire expressed its "deepest sympathies" to the families and friends of those who dies, and said it would "need time" to study the inquiry's findings to identify any areas where it might improve practice.

Brian Sweeney, Strathclyde Fire and Rescue chief officer, said firefighters had had a difficult time when they arrived at the care home. He said: "It should be remembered that Rosepark was no ordinary fire. The sheriff lists 14 unique factors of which our staff could not have been aware. These factors, together with the considerable delay in reporting the fire, left us with a near-impossible task."

He said comments from the sheriff on the Care Commission, the health board, the home's owners and the staff "must now be the focus of attention".

He added: "These observations reveal a catalogue of errors that must never be allowed to happen again. The real tragedy is that most of the Rosepark victims died before we arrived. The nine-minute delay in calling us was crucial."

No criminal charges over tragedy

PREVIOUS legal action against the owners of Rosepark has not resulted in any convictions, and it is unlikely any new action will be brought now.

A criminal case against Thomas Balmer collapsed in 2007, and charges brought under a new indictment the next year were later dropped. Charges against the Balmer family on alleged safety breaches were dropped after the judge dismissed them on a legal technicality.

Ahead of the FAI, in order to ensure all parties involved could participate, the Crown Office confirmed there would be no further criminal prosecutions.

Some parties want a full public inquiry into the failure to successfully bring criminal charges.