Bad fire safety caused care home deaths

Fire safety plans at a residential care home where a blaze killed 14 residents were "systematically and seriously defective", a fatal accident inquiry concluded today.

The fire at Rosepark care home in Uddingston, Lanarkshire, broke out in a cupboard overnight on January 31 2004 and ripped through the building.

Four people were also injured in the fire.

Sheriff principal Brian Lockhart this morning published his findings following a 141-day inquiry. He found that "some or all" of the deaths could have been prevented if the home, run by Anne and Thomas Balmer, had a "suitable and sufficient" fire safety plan.

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 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.

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".

Lanarkshire Health Board had a "deficient way of working" which failed to pick up on fire risks within Rosepark, the determination found. Mr Lockhart said the board had a "mistaken belief" that fire services were responsible for inspecting the home for fire risks.

In his conclusion, Mr Lockhart said: "The purpose of the conclusions drawn is to assist those legitimately interested in the circumstances of the death to look to the future in order that they may be persuaded to take steps to prevent any recurrence of such a death in the future.

"It would be surprising, with a tragedy of this magnitude, if there had not been developments of a significant nature since the fire took place.

"I would like to say to the relatives of those who so tragically lost their lives in the Rosepark fire that all of us involved in the inquiry offer our sincerest sympathies. We express our admiration for the manner in which they conducted themselves through the long and difficult days when evidence was taken.

"It is to be hoped that this determination provides answers to their questions. We wish them all well."

A spokesman for the owners of Rosepark Care Home said: "Our legal team is studying the determination issued by Sheriff Principal Brian Lockhart. We have nothing further to add at present."