ROSEPARK FATAL ACCIDENT INQUIRY: FINDINGS OF SHERIFF PRINCIPAL

[colin todd]

The findings of the fatal accident inquiry are now published. Available below.

http://www.scotcourts.gov.uk/opinions/2011FAI18.html.  

There is a wealth of findings and recommendations that are extremely important to our profession.

While it is out of context to refer to any one in a bulletin board, given the extent of the findings and recommendations, I wonder if my good friend Kurnal would like to review what, for me, was his most famous shoot first and ask questions later comment, which, as I found it very inappropriate, I reproduce below (with the hope he will not be offended):

KURNAL:  QUOTE BEGINS  "And why the personal criticism and hostile questioning of employees for suggesting that it may be appropriate to investigate a fire alarm before callng the fire service? Why do the highly paid barristers and QCs have to be so ill informed and hostile? Have they not researched the topic? Have they not looked at what CFOA is saying Nationally before setting into a poor handyman employee.

I will offer my reason. Its because the British Legal system is all about the biggest bully winning the argument, not about whether the person is guilty or not. Ego trips for overpaid lawyers is the name of the game."   QUOTE ENDS

The views of Kurnal (based on the policies of some ENGLISH fire and rescue services) appear to be at odds with those of the Sheriff Principal, which I further reproduce below:

 SHERIFF PRINCIPAL: START QUOTE " In the case of a residential care home, where one is dealing with a large life risk to elderly people, it is absolutely essential that the home's fire procedure should require a call to the Fire Brigade immediately the fire alarm sounds[4074].



3.          There are no circumstances in which one would condone a procedure that involved sending members of staff to look and see if there was a fire before calling the Fire Brigade. Any delay would be a matter of grave concern[4075]. END QUOTE

As we reflect on this very sad tragedy, I wonder if Kurnal might wish to retract his comments about the not very well paid and hard working lawyers of the Scottish Procurator Fiscal Service and the Crown advocates (not "barristers" in Scotland Kurnal), the salaries of whom I am not aware (though Kurnal may somehow be party to this information).

The Sheriff Principal concludes that, had there been earlier deployment by the fire and rescue service (delay in which was partly due to the 9 minute delay in making the 999 call) four of the deceased might have survived.

[jayjay]

Thanks for the link Colin.

I have started to read the document and it is cetainly very detailed and informative.

I would like to ask Collin if he is aware if it is proposed to publish the report in a printer friendly or PDF format?

I think we will all learn from this reading and probably many will be familiar with some of the situations and difficultys that arose.

[CivvyFSO]

RP3.3 Fitting Smoke Seals to Bedroom Doors (see Chapter 44(3)(C) hereof)

It would have been a reasonable precaution to have fitted smoke seals to bedroom doors. Had this precaution been taken the deaths of Robina Burns and Isabella McLeod might have been avoided.

Colin, does this throw your argument of "Show me where deaths have been attributed to the lack of strips & seals" out? Admittedly, it only says the deaths 'might' have been avoided. Maybe it would be a more reasoned argument to ask where it can be shown that strips and seals have been attributed to saving lives? The problem there being that there is never a detailed enquiry when things go right.

[CivvyFSO]

I would like to ask Collin if he is aware if it is proposed to publish the report in a printer friendly or PDF format?

Jayjay

Click in the browser window
Press [ctrl]A
(wait a bit since it is a long document)
Open MS Word
Press [ctrl]v
(wait a bit again)

It pastes in perfectly.

Almost 1000 pages though, so you might need to stock up on printer ink.

[jayjay]

Thanc CivyFSO

I have created a PDF document of the report now and its 628 pages, done this by printing to CutePDF which is a free PDf creator.

If any one can't do it and wants a copy send me your email.

It would be good if building plans and photographs were available.

[FSO]

OK, so coming back to Colin's post.

How do these recommendations sit with quite a few FRSs deciding not to respond to AFAs unless there is confirmation of a fire?

Dangerous game!

Unfortunately, the generic response from FRSs seems to be "Its your risk to manage" and "We have no statutory requirement to attend any incident, let alone AFAs".

I hope this document provokes a strong consideration of what is being proposed by many fire authorities.

[kurnal]

Thanks To Colin for the link. Let us hope that this prompts a thorough review of procedures thoughout the UK.
My comments as you have quoted at the time were in response to a specific news story which give an account of a cross examination of a handyman by a QC who was working on behalf of the Strathclyde Fire and Rescue Service.

http://www.heraldscotland.com/news/crime-courts/care-home-owner-tells-inquiry-she-did-not-see-fire-safety-as-her-remit-1.1041853

One has to rely on news stories unless one is privileged to be present at such events. Clearly one should not allow such news stories to colour ones opinion. My original posting - of which you have only quoted one part was indeed a knee kerk reaction to reading several news stories. My posting was indeed ill advised and ill informed as you continue to point out at regular intervals.

http://fire.org.uk/forum/index.php?topic=4910.0

But I still think the complete posting reflected what appears as the very different treatment of a handyman under cross examination by a QC working on behalf of a fire and rescue service whereas others, eg the Chief Fire Officer, (if we could believe the press reports as being something approaching a true and complete record)- appear to be free to make statements without having these tested or challenged.

http://www.heraldscotland.com/news/home-news/call-to-regulate-safety-assessors-1.1040914

It is clear that the fire and rescue service should be called without delay, but it is also fair to say that hitherto it has been frequently suggested that occupiers, as part of an unwanted signals reduction strategy, should check the cause of the alarm before making a 999 call. The latest CFOA strategy, published in September 2010 has clarified things to a great extent, but previously the situation was not so clear, and there is no doubt that some fire services and officers were applying sections of IRMP guidance note 7 fairly liberally when attending unwanted signals and encouraging investigfation by staff before dialling 999.

http://www.communities.gov.uk/documents/fire/pdf/130352.pdf

[jayjay]

Just a further update on the reports.

There is more information know as "The Appendicies to the report" available on the scotscourts web site, not had a chance to compare them but does have a detailed section of the events immediatley prior to and during the incident.



http://www.scotcourts.gov.uk/opinions/APPENDICES.html

[CivvyFSO]

It is worth considering that many FRS' challenge 999 calls now. So even if the call had been made immediately, the person making the call might have been asked to go check, depending on the FRS concerned.

[colin todd]

Before too much further misinformation is widely circulated, I will make these points and try to avoid making further comment, as the Sheriff Principal took great time and care to listen to evidence and write one of the best Inquiry reports I have read in my career. I suggest people take the time to read it before firing off a salvo of further comment.

Civvy. No it does not throw out my arguements about strips and seals, it strongly supports them.  Indeed, it is the strongest support for my arguements on the subject I have ever come across.  Own goal, there Civvy I am afraid.The Inquiry heard evidence of experts on the effect that NON FIRE RESISTING DOORS would have had if they had only been closed. I suggest you read the Inquiry report very carefully and then promote the messages emanating from it. The need for smoke seals should be based on a risk assessment that takes time to evacuate into account. This is particularly relevant in certain care homes.

Kurnal, You are talking about some  FRS in England. When will you begin to understand that Scotland is a different country, that CFOA Scotland have not endorsed the CFOA policy in England, that things are very different in Scotland, there were NO FRS in Scotland, declining to attend AFAs, and please take the trouble to read issues on the summoning of the FRS. Try to be still until you have done so.

Civvy, You make the same mistake as Kurnal.  At the time in question, NO Scottish FRS call challenged in the way you suggest, nor would any of them, in the case of a call to a care home at night, do so today.  The 8 Scottish FRS are as joined up in their thinking on matters as you will find in the British fire service. As an aside, even after a fire as serious as this, the senior fire safety officer of a west country FRS in England sat before myself and a client, threatening enforcement action if , in small care homes of the client, with few staff on at night, they did not investigate tfire alarm signals. We told him to bring it on and we would see him at the mags Court. Strangely nothing happened. I will be emailing a copy of the FAI determination to their current much more forward thinking Senior fire safety officer, to remind him of the views of his predecessor.

As a Crown expert witness in the FAI,  I think it inappropriate to discuss this determination in any more detail.  Please take the trouble to read the determination and try to avoid commenting on half truths you may read second hand.

[Phoenix]

At one point the report states, "He suggested that the Care Home Guidance be amended .... that acoustically-linked hold-open devices should not be used to hold open doors to staircases."

Why is this a valid suggestion?  Is it because staircases are vital and because their availability must be reliable.  Is such a device less likely to protect the stairs than a common alternative, the wedge?  Are all staircases so vital or, due to the layout in some premises, are there stairs that are not critical for means of escape?  What about accommodation stairs?  I'm not a great supporter of such devices and if they don't work, bad, but if they do, then fine (wherever they are fitted).  If this is a suggestion with sound reasoning behind it then, at the moment, I am unable to see that reasoning and I would be very grateful if someone could point it out.

Stu

[kurnal]

Stu I guess the report is only moving things along in the direction suggested by BS 7273 part 4. When this was introduced in 2007 it introduced the concept of grades of system - grade A being the most resilient and Grade C being the least resilient. Tables in the standard identified suggested grades for a number of scenarios- but the footnote made the point that the grading of devices in this way was a new concept and that it would take some time before the concept was incorporated into the occupancy based technical standards documents. I guess the Sherriff Principal is moving things in this direction. BS 7273 part 4 would suggest that any doors leading to a staircase in a care home should only be held open using a Grade A device. A dorgard is Grade C.

I know where you are coming from though, I recently recommended to the owner of a Victorian nursing home that he should  replace the dorgards on the staircase with a more resilient arrangement. When I went back a 3 weeks later to deliver a training course the dorgards had been removed. And staff had replaced them with wedges.