SHERIFFDOM OF SOUTH STRATHCLYDE …

1 SHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30] SHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 DETERMINATION BY SHERIFF PRINCIPAL BRIAN A LOCKHARTIN RESPECT OF THE INQUIRY INTO THE DEATHS OF Annie (Nan) StirratJulia McRobertsRobina Worthington BurnsIsabella MacLeodMargaret LappinMary McKennerEllen (Helen) Veronica MilneHelen (Ella) CrawfordAnnie Florence ThomsonMargaret Dorothy (Dora) McWeeThomas Thompson CookAgnes DennisonMargaret McMeekin GowIsabella Rowlands MacLachlan INDEX Chapter NoHeading1 IntroductionSHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30]2 Findings under section 6(1) of the 1976 Act (a) Index (b) My Findings (c) Conclusions from the Findings3 Rosepark Care Home: Location and Layout4 Management and Staffing at the time of the fire5 Residents on 30-31 January 20046 Construction of Rosepark Care Home7 Registration8 The Ventilation System9 The Fire Alarm System10 The Washing Machines11 The Electrical Installation12 Maintenance of the Electrical Installation13 Cupboard A214 Cross-corridor Doors15 Bedroom Doors16 Policies17 Fire Safety Notices18 Fire Safety.

2 Roles and Responsibilities19 The Emergency PlanChapter NoHeading20 Fire Training and Fire Drills21 Evacuation and its Difficulties22 The Millennium Bug and the Fireman s Strike23 False Alarms24 James Reid s Involvement Fire Risk Assessment25 Section1(1)(d) Visits and Risk Categorisation of Rosepark26 The Interaction between Rosepark and Lanarkshire Health Board1992 2002 27 The Care Commission and its Interaction with Rosepark 2002 2004 SHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30]28 The Events of 30 31 January 200429 The Position of Bedroom Doors on the Night of the Fire30 The Location of the Fire31 The Development of the Fire: The BRE Work32 Development of the Fire from Ignition to Flaming Combustion33 BRE Test 1 a Reasonable Representation of the Fire at Rosepark 34 The Development of the Fire: The Role of Aerosols35 The Development of the Fire: The Role of Furniture36 The Development of the Fire: The Evidence of Mrs Burns37 The Development of the Fire: Corridor 338 When Did Ignition Occur?

3 39 Smoke and Toxic Fire Gases40 Effects of Toxic Atmosphere on the Occupants of Corridors 3 and 4 41 Where and When Did Each Death Take Place Chapter NoHeading42 The Cause of Causes of the Death of Each Deceased43 The Cause of the Fire Section 6(1)(c): The Reasonable Precautions Whereby the Deathsor the Accident Resulting in the Deaths Might have been Avoided 44(1)RP1 - Cable Protection the Insulation at the Cable V Knockout 44(2)RP2 - Inspection and Testing of the Electrical Installation44(3)(A) - Cupboard Doors44(3)(B) - Closed Bedroom Doors44(3)(C) - Fitting Smoke Seals to Bedroom Doors44(3)(D) - Storage of Combustible materials44(3)(E) - Sub-division of Corridor 444(3)(F) - Fire Dampers44(4)RP4 - Prompt, Accurate and Effective Action by Staff44(4)(A) - Provision of Clear Information at the Fire Alarm Panel SHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41.]

4 30]44(4)(B) - Staff to have been Provided with Adequate Training andDrills 44(4)(C) - Isobel Queen to have been given Instruction in Relation tothe new Fire Alarm Panel 44(5)The Events of the Night Early Involvement of the Fire Brigade 44(6)RP6 Suitable and Sufficient Risk Assessment44(7)RP7 Early and Sufficient Resourcing of the Incident of the FireBrigade Chapter NoHeading Section 6(1)(d): Defects in the Systems of Work which Caused orContributed to the Deaths 45(1)DS1 Defective System of Work as Regards maintenance of theElectrical Installation 45(2)DS2 Defective System of Work as Regards Fire Training and Drills 45(3)DS3 Defective System of Work as Regards the Management of FireSafety 45(4)DS4 Defective System of Work as Regards the Management of theConstruction Process 45(5)DS5 Defective System of Work as Regards Defects in the Systemof Working of Lanarkshire Health Board Section 6(1)(e): Other Facts Relevant to the Circumstances of theDeaths 46(1)OF1 Enforcement of the Fire Precautions Regulations46(2)OF2 The Care commission and its Interaction with Rosepark 46(3)OF3 Statutory Responsibility for Fire Safety.

5 The Care Commissionand STRATHCLYDE Fire & Rescue s Understanding of Their RespectiveRoles 46(4)OF4 Certificate of Completion: The Position of the Architect andBuilding control Authority Recommendations thereon46(5)OF5 Checking of Documentation Recommendations thereon46(6)OF6 Assurance as to the Competence of Fire Risk Assessors andSHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30]the Current Position of Scottish Ministers Response of Scottish Ministers and my comments thereon ( ) Chapter NoHeadingPage No46(7)Developments since the Rosepark FireTHESE HAVE BEEN SET OUT FULLY IN MY FINDINGSIN CHAPTER 2 AND THE PAGE NUMBERS WHICHFOLLOW IN RELATION TO OF7, OF8, OF9 AND OF10 ARE THE PAGE NUMBERS IN CHAPTER 2 At the instigation of Scottish Ministers, a process ofadvisory visits by Fire Services to Care Homes throughoutScotland was instigated following the fire 59 Memoranda of Understanding were, in 2005, enteredinto between the Care Commission and the eight Fire andRescue Authorities in Scotland 60 STRATHCLYDE Fire and Rescue issued OperationalTechnical Note A124, in response to certain recommendationswhich had been made by Sir Graham Meldrum following thefire at Rosepark Care Home 63 My conclusions thereon and recommendations ( )

6 69 OF4 The legislation in relation to fire safety which had beenin place at the time of the fire was replaced by acomprehensive new legislative framework, in the Fire(Scotland) Act 2005 a summary of the legislative position prior to theenactment of Part III of the Fire (Scotland) Act 2005 71 the legislative history of the Fire (Scotland) Act 2005 72 the relevant sections of Part III of the Fire (Scotland)Act 2005, which in particular specify that the enforcingauthority in terms of the Act is a Fire and Rescue Authority,(or a joint Fire and Rescue Board where a scheme forcombining two or more Fire and Rescue Authorities has beenimplemented in terms of section 2(1) of the 2005 Act). 73 the relevant sections of The Fire Safety (Scotland)Regulations 2006 77 Strategic Enforcement Guidance for Fire and RescueAuthorities issued by Scottish Ministers in August 2006 thiswas not sector specific 79 SHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30] Chapter NoHeadingPage No Fire Safety Guidance Booklet and preparation ofsection specific guidance 80 Practical Fire Safety Guidance for Care Homes latestversion published by Scottish Government in February 2008 81 Conclusions 82 Part III of the 2005 Act and the Care Commission.

7 Care Commission no longer responsible for considering firesafety measures. That responsibility lies with the Fire andRescue Services. 82 enforcement of the 2005 Act and the 2006 Regulationsby SFRS 84 current approach of Care Commission to the Fire(Scotland) Act 2005 85 Conclusions and recommendations 88 OF8 developments in the Building Regulations since theRosepark Fire 89 OF9 Developments which have taken place at Rosepark CareHome since the Fire 91 OF10 Future Developments in the Regulatory Field 93 Recommendations 9446(11)OF11 the Recommendations of Colin Todd, the response ofScottish Ministers, and my comments thereon (Chapter 46(10)) Appendices containing written submissions of interested parties at end of Determination - separate index CHAPTER 1: INTRODUCTION AND SCOPE OF THE INQUIRY 1. This is an Inquiry instituted by the Lord Advocate under the discretionary provisions of the Fatal Accidents andSudden Deaths Inquiry (Scotland) Act 1976 ( the 1976 Act ).

8 On 31 January 2004 a fire broke out at Rosepark CareHome, 261 New Edinburgh Road, Uddingston. Following the fire, ten residents of the home were found dead at thescene. Four residents were rescued alive, but subsequently died in hospital. 2. In July 2009 a petition was presented by the Procurator Fiscal under the 1976 Act intimating that thecircumstances of the deaths were such as to give rise to serious public concern and that it appeared to the LordSHERIFFDOM OF SOUTH STRATHCLYDE dumfries AND galloway file:///C|/ [19/05/2011 10:41:30]Advocate to be expedient in the public interest that an Inquiry be held into the circumstances of those deaths. 3. Evidence was heard over 141 days between 16 November 2009 and 12 August 2010. Evidence was led from atotal of 212 witnesses, at the GLO Centre, Motherwell which had been specially adapted to accommodate this Inquiry.

9 4. Parties were represented at the Inquiry as follows:The Lord Advocate: James Wolffe, QC, Advocate Depute and Robert Weir, Advocate DeputeThomas Balmer, Mrs Ann Balmer and Mr Alan Balmer: by P G McBride QCStrathclyde Fire & Rescue Service: P Wade, Solicitor AdvocateNHS Lanarkshire: G Coll, AdvocateThe Care Commission of Scotland: D Thomson, Solicitor AdvocateNorth Lanarkshire Council: Ms R McCormick, SolicitorScottish Ministers: D Ross, AdvocateGeorge Muir: Ms C McMenamin, SolicitorAlexander Ross: C Marney, AdvocateSarah Meany: A Murphy, AdvocateIsabel Queen: M Blessing, AdvocateBrian Norton: Ms E Toner, AdvocateIrene Richmond: G. Whyte, SolicitorYvonne Carlisle: Ms P Thornton, AdvocateJoseph Clark: Ms A Taggart, AdvocateJames Reid: Ms G Ross, Advocate 1. Section 6(1) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 ( the 1976 Act ) providesthat at the conclusion of the evidence and any submissions thereon the sheriff shall make a determination setting outthe following circumstances of a death as far as they have been established to his satisfaction: (a) where and when the death and any accident resulting in the death took place;(b) the cause or causes of death and any accident resulting in the death;(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;(d) the defects, if any, in any system of working which caused or contributed to the death or any accident resulting in the death; and(e) any other facts which are relevant to the circumstances of the death.

10 Accident has been described, in the context of the 1976 Act, as an unfortunate incident that happens unexpectedlyand unintentionally, typically resulting in damage or injury . 2. At the conclusion of the evidence, I was of the opinion that it was impractical to have oral submissions in view ofthe number of parties and the number and complexity of the issues involved. The Crown accepted my suggestion thatit was for the Crown, who had sought this Inquiry, to produce draft findings in fact and proposed findings that I shouldmake in terms of section 6(1) of the 1976 Act. The Crown set out the factual basis for the proposed findings in a seriesof narrative chapters and then set out their proposals on the various issues which fall to be determined by statute. I amvery grateful to the Crown for the very detailed submissions which they produced.