Concerns over care home ‘not recorded in safety report’

Investigator tells Rosepark inquiry ‘serious shortcomings’ were omitted

By Cordelia O’Neill

Published: 18/02/2010

A fire-risk assessment at a nursing home where 14 residents died in a blaze uncovered “serious shortcomings” that were not recorded, an inspector has admitted.

Giving evidence to an inquiry into the fire at the Rosepark Nursing Home in Lanarkshire six years ago, John Reid said his report a year before the tragedy had not included key findings that had caused him “concern”.

As well as the 14 deaths, four residents were injured when the blaze broke out in a cupboard at the home on January 31, 2004.

A fatal accident inquiry is trying to establish the full circumstances of the tragedy, to prevent a similar fire from happening again and establish if any precautions could have been taken to avoid the deaths.

Mr Reid was employed on a retainer basis by the home’s owners, Thomas, Alan and Anne Balmer, to carry out health and safety inspections and offer recommendations for improvements in January 2003.

But while the report given to the Balmers warned the controls in place were not adequate to reduce the risk of a fire, he omitted information that could have helped prevent, or lessen, the impact of the fire.

These included failing to include the residents of the home in a list of people who might be at risk.

They also included failing to check and record documents relating to staff fire training and fire procedures, and failing to record that fire doors to residents’ bedrooms had been propped open and the safety catches disabled.

He said he had noted and raised the issue with the Balmers but was told the residents became distressed when the doors were left shut, adding he had been “concerned but understood why they had done it”.

Mr Reid told the inquiry he had not been aware of the home’s policy of investigating a fire alarm sounding before calling emergency services.

He said, had he known, he would have told the Balmers it was “not a suitable procedure” and that staff should have been told to dial 999 immediately.

The problems came to light during an inspection of the home in which fire exits and extinguishers, staff training and other fire risks were checked.

Mr Reid told the inquiry that, while he had not documented his concerns, all of the issues had been discussed with the Balmers.

Under questioning from Crown counsel James Wolffe QC, he admitted failing to inspect documents detailing what training and information staff had been given in the event of a fire meant he could not have “a sufficient base for answering in the affirmative questions about sufficient and adequate safety training, undermining the basis of his later advice”.

He also agreed that “any risk assessment which did not address risks to the residents could not be a sufficient and suitable risk assessment”.

Mr Reid also told the inquiry he was unaware of two key documents produced by the Home Office and the Scottish Health Service that specifically addressed fire risks in care homes.

Questioned by Paul McBride QC, who is representing the Balmers, Mr Reid accepted he had lacked the “competence and qualifications” to carry out the work he was employed to do.