Fatal Accident Inquiry into the Deaths at Rosepark Nursing Home, Sheriff Principal Brian Lockhart, 19th April 2011

In terms of s.6(1)(c) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the sheriff found that a number of reasonable precautions could have been taken to avoid the deaths. These were:
1. The loose cable that caused the fire could have been better protected.
2. Electrical installations could have been regularly inspected and tested.
3. The cupboard where the fire started could have been kept securely closed.
4. Bedroom doors could have been fitted with smoke seals and automatic close mechanisms.
5. Combustible material could have been stored away from the cupboard's electrical installations.
6. The corridor in which the cupboard was situated could have been subdivided to reduce the number of residents to be evacuated.
7. Fire dampers could have been installed.
8. The fire alarm panel could have been better designed to provide clearer information.
9. Better training could have been given to staff.
10. Staff could have phoned the fire brigade as soon as the alarm sounded.
11. Staff could have undertaken adequate risk assessment.
12. Fire Brigade staff could have made earlier calls for more resources had they been made fully aware of the situation.

In terms of s.6(1)(d) a number of defects in systems of work were identified as causing or contributing to the deaths. The following systems were inadequate:
1. Maintenance of electrical installations.
2. Staff training in fire procedure.
3. Management of fire safety.
4. Management of the Rosepark's construction process.
5. Regulation of nursing homes by Lanarkshire Health Board.

In terms of s.6(1)(e) a number of facts were identified as relevant to the circumstances of the deaths. These were:
1. Fire precautions legislation requiring fire brigades to inspect care homes was not complied with. The legislation only required the Care Commission to inspect fire safety records and not equipment. The two bodies were not clear about their respective roles with respect to fire safety.
2. A completion certificate was awarded to Rosepark when it had failed to comply with building regulations in respect of the installation of fire dampers.
3. There was no external check to ensure that ventilation and electrical installations had been inspected and tested.
4. There was no statutory requirement for persons assessing fire risk to be suitably qualified.