Please see the Article below, a wake up call for many Risk assessors about what to include in an FRA.
Rosepark care home blaze: 'Serious shortcomings' were not included in report, inspector tells FAI
Feb 17 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 admitted today.
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, 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 that 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 in the event of a fire, failing to check and record the 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 that he had been "concerned but understood why they had done it".
Mr Reid told the inquiry, at the Gospel Literature Outreach Centre in Motherwell, that 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.
He also admitted that he was "unaware" of, and hadn't checked, two fuse boxes, although he had checked that the main fuse box for the care home was securely locked.
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 hadn't documented his concerns, all of the issues had been discussed verbally with the Balmers during the inspection.
He told the inquiry: "There were serious shortcomings, that should have been documented, left out.
"I won't say that because they weren't recorded they hadn't been considered, but they should have been in there.
Under questioning from Crown Counsel James Wolffe QC, he admitted that 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 with the Advocate Depute 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 residential care homes.
The inquiry, before Sheriff Principal Brian Lockhart, is expected to last between four and six months.
An attempt to prosecute the home's owners, Thomas, Anne and Alan Balmer, over alleged safety breaches collapsed in 2007 after a judge dismissed the charges.
A fresh indictment was served in 2008, but those charges were also dropped.
