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


This was a fatal accident inquiry into the deaths of 14 residents of Rosepark Care Home; Annie Stirrat, Julia McRoberts, Robina Worthington Burns, Isabella MacLeod, Margaret Lappin, Mary McKenner, Ellen Veronica Milne, Helen Crawford, Annie Florence Thomson, Margaret Dorothy McWee, Thomas Thompson Cook, Agnes Dennison, Margaret McMeekin Gow and Isabella Rowlands MacLachlan. The sheriff found that all 14 residents died as a result of a fire at the care home on 31st January 2004.

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.

Since the fire a number of significant developments have served to improve fire safety in care homes. The fire brigade carried out advisory visits to all care homes to eliminate fire safety risks and overhauled its procedures for dealing with fires in nursing homes. The Care Commission appointed a Fire Safety Advisor to ensure that the two bodies work more closely on fire safety. Memoranda of understanding were drawn up between them. The regulatory framework in relation to fire safety was strengthened by the Fire Safety (Scotland) Regulations 2004. Finally, building standards regulations were also reviewed to address fire safety concerns.