Appendices To The Rosepark Nursing Home Fatal Accident Inquiry
| Jurisdiction | Scotland |
| Judge | Sheriff Principal Brian A Lockhart |
| Neutral Citation | [1088] Pro 334H |
| Court | Fatal Accident Determinations (Scotland - United Kingdom) |
| Date | 19 April 2011 |
| Docket Number | Matron/Care |
| Published date | 20 April 2011 |
ROSEPARK FATAL ACCIDENT INQUIRY
APPENDICES
INDEX
SUBMISSIONS FOR PARTIES
| Appendix 1.1 | |
| Appendix 1.2 | |
| Appendix 1.3 | |
| Appendix 1.4 | |
| Appendix 2 | |
| Appendix 3 | |
| Appendix 4 | |
| Appendix 5 | |
| Appendix 6 | |
| Appendix 7 | |
| Appendix 8 | |
| Appendix 9 | |
| Appendix 10 | |
| Appendix 11 | |
| Appendix 12 | |
| Appendix 13 | |
| Appendix 14 | |
| Appendix 15 |
ROSEPARK FATAL ACCIDENT INQUIRY - SUBMISSIONS FOR THE CROWN
1. Introduction
2. The law of evidence
3. Rosepark Care Home: Location and Layout
4. Management and Staffing at the time of the Fire
5. Residents on 30-31 January 2004
6. Construction of Rosepark Care Home
7. Registration
8. The Ventilation System
9. The Fire Alarm System
10. The Washing Machines
11. The Electrical Installation
12. Maintenance of the Electrical Installation
13. Cupboard A2
14. Cross-corridor doors
15. Bedroom doors
16. Policies and procedures
17. Fire Safety Notices
18 (formerly 17A) Fire Safety Responsiblities
19 (formerly 18) The Emergency Plan
20 (formerly 19) Fire training and fire drills
21(formerly19A) Evacuation and its difficulties
22 (formerly 20) The Millenium Bug and the Fire Brigade Union Strike
23 (formerly 21) False alarms
24 (formerly 22) Mr. Reid
25 (formerly 22A) 1(1)(d) visits and risk categorization of Rosepark
26 (formerly 22B) Interaction with Lanarkshire Health Board
27 (formerly 22C) Interaction with Care Commission
28 (formerly 23) The events of the night
29 (formerly 24) The status of bedroom doors during the fire
30 (formerly 25) The Location of the Fire
31 (formerly 26) Development of the fire: the BRE work
32 (formerly 27) Development of the fire from ignition to flaming combustion
33 (formerly 28) BRE Test 1 a reasonable representation of the development of the fire at Rosepark
34 (formerly 29) Development of the fire: the role of Aerosols
35 (formerly 30) Development of the fire: the role of Furniture in the corridor
36 (formerly 31) Development of the fire: the evidence of Mrs. Burns
37 (formerly 32) Development of the fire: corridor 3
38 (formerly 33) When did ignition occur?
39 (formerly 34) Smoke and Toxic Fire Gases
40 (formerly 34A) Effects of Toxic Atmosphere on Occupants of Corridors 3 and 4
41 (formerly 35) Where and When each Death took Place
42 (formerly 36) The Cause or Causes of Death of Each Deceased
43 (formerly 37) The Cause of the Fire
44 (formerly 38) Reasonable precautions
(1) Cable protection
(2) Inspection and testing of the electrical installation
(3) Protection of the means of Escape
(A) Cupboard doors
(B) Bedroom doors
(C) Smoke seals
(D) Storage of aerosols
(E) Subdivision of corridor
(F) Fire dampers
(4) Prompt and effective action by staff
(A) Information at the panel
(B) Training and drills
(C) Instruction in the new panel
(5) Early involvement of the Fire Brigade
(6) Risk assessment
(7) Early and Sufficient Resourcing of the Incident by the Fire Brigade
45 (formerly 39) Defects in systems of work
(1) Inspection and testing of the electrical installation
(2) Training and drills
(3) Management of fire safety
(4) Management of the construction process
(5) Interaction between Rosepark and the Health Board
46 (formerly 40) Other matters
(1) Enforcement of the Fire Precautions Legislation
(2) Statutory Responsibility for Fire Safety: Care Commission and Strathclyde Fire and Rescue understanding of their respective roles
(3) Certificate of Completion: the position of the Architect and Building Control Authority
(4) Checking of documentation re testing and inspection of electrical installation and ventilation system
(5) Competence of risk assessors
(6) Developments since the Rosepark fire
(A) The immediate aftermath
(B) Strathclyde Fire & Rescue
(C) The Fire (Scotland) Act 2005, its Regulations and its Consequences
(D) Building Standards
(E) Rosepark Care Home
(F) Mr. Todd
PROPOSED DETERMINATIONS
Section 6(1)(a) - when and where the death took place [Chapter 41 (formerly 35)]
1 Robina Burns died in the Coronary Care Unit at Glasgow Royal Infirmary at or about 7 p.m. on 2 February 2004.
2 Thomas Cook died in room 16 at Rosepark Care Home at or about 4.38 am on 31 January 2004
3 Helen (Ella) Crawford died in room 14 at Rosepark Care Home at or about 4.38 am on 31 January 2004
4 Agnes Dennison died in room 17 at Rosepark Care Home at or about 4.38 am on 31 January 2004
5 Margaret Gow died at Stobhill Hospital at or about 10.40 am on 2 February 2004.
6 Margaret Lappin died in room 12 at Rosepark Care Home at or about 4.39 am on 31 January 2004
7 Isabella Maclachlan died at Wishaw General Hospital at or about 3.35 am on 1 February 2004
8 Isabella MacLeod died at Stobhill Hospital at or about 4.45 pm on 1 February 2004
9 Mary McKenner died in room 13 at Rosepark Care Home at or about 4.39 am on 31 January 2004
10 Julia McRoberts died in room 9 at Rosepark Care Home at or about 4.38 am on 31 January 2004
11 Margaret Dorothy (Dora) McWee died in room 15 at Rosepark Care Home at or about 4.38 am on 31 January 2004
12 Ellen (Helen) Milne died in room 13 at Rosepark Care Home at or about 4.38 am on 31 January 2004
13 Annie (Nan) Stirrat died in room 9 at Rosepark Care Home at or about 4.38 am on 31 January 2004
14 Annie Thomson died in room 14 at Rosepark Care Home at or about 4.38.30 am on 31 January 2004
Section 6(1)(a) - when and where the accident resulting in the deaths took place
Where ... the accident resulting in the deaths took place [Chapter 30 formerly 25)]
1. Each of the deaths resulted from a fire which occurred at Rosepark Care Home on 31 January 2004.
2. The fire started low down on the south side of the cupboard known as cupboard A2 in the upper corridor of Rosepark Care Home.
When ... the accident resulting in the deaths took place [Chapter 38 (formerly 33)]
The fire started at or about 04.25 am on 31 January 2004.
Section 6(1)(b) - the cause or causes of death [Chapter 42 (formerly 36)]
1. The death of Robina Burns was caused by acute tracheobronchitis due to inhalation of smoke and fire gases. Ischaemic heart disease due to coronary artery atheroma and cardiac amyloidis were potential contributing causes.
2. The death of Thomas Cook was caused by the inhalation of smoke and fire gases.
3. The death of Helen (Ella) Crawford was caused by the inhalation of smoke and fire gases.
4. The death of Agnes Dennison was caused by the inhalation of smoke and fire gases.
5. The death of Margaret Gow was caused by bronchopneumonia due to the inhalation of smoke and fire gases.
6. The death of Margaret Lappin was caused by the inhalation of smoke and fire gases.
7. The death of Mary McKenner was caused by the inhalation of smoke and fire gases.
8. The death of Isabella MacLachlan was caused by bronchopneumonia due to inhalation of smoke and fire gases. Chronic obstructive airways disease was a potentially contributing cause of death.
9. The death of Isabella MacLeod was caused by bronchopneumonia due to hypoxic brain damage and the inhalation of smoke and fire gases.
10. The death of Julia McRoberts was caused by the inhalation of smoke and fire gases.
11. The death of Margaret Dorothy (Dora) McWee was caused by the inhalation of smoke and fire gases.
12. The death of Ellen (Helen) Milne was caused by the inhalation of smoke and fire gases.
13. The death of Annie (Nan) Stirrat was caused by the inhalation of smoke and fire gases.
14. The death of Annie Thomson was caused by the inhalation of smoke and fire gases.
Section 6(1)(b) - the cause or causes of the accident resulting in the deaths [Chapter 43 (formerly 37)]
The accident resulting in the deaths was caused by an earth fault occurring where Cable V passed through the knockout at the back of the distribution box in cupboard A2.
Section 6(1)(c) - the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided.
Insulation at the Cable Knockout [Chapter 44(1) (formerly 38(1))]
1. It would have been a reasonable precaution:-
(a) for a grommet or other cable protection to have been fitted at the upper righthand knockout of the distribution board when the system was installed and, in any event, when Cable V was installed; and
(b) for the installation to have been undertaken in such a manner that the outer sheath of Cable V was protecting the inner cores as they passed through the knockout.
2. Had there been a grommet in place, or if the outer sheath of Cable V had been protecting the inner cores as they passed through the knockout the accident and the deaths might have been avoided.
Inspection and Testing of the Electrical Installation [Chapter 44(2) (formerly 38(2))]
1. It would have been a reasonable precaution for the distribution board to have been inspected and tested in accordance with the IEE Regulations at least on the following occasions:-
1.1. On completion of the electrical installation at Rosepark in 1992;
1.2. When the system was modified to add Cable V; and
1.3. Not later than the fifth and tenth anniversaries of the completion of the electrical installation.
2. Had the system been inspected and tested in accordance with the IEE Regulations, the accident and the deaths might have been avoided.
Cupboard Doors [Chapter 44(3)(A) (formerly 38(3)(A))]
1. It would have been a reasonable precaution for the doors to cupboard A2 to have been kept locked shut or at least securely closed.
2. Had the doors of cupboard A2 been securely closed, the deaths might have been avoided.
And
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