Health Service Focus

Fire safety duties

NHS trust and foundation trust chief executives and NHS trust boards have been reminded of their fire safety duties by David Flory, deputy NHS chief executive. Adam Hewitt reports.

Ascathing fire service report into a fi re on the site of Ipswich hospital has identified a series of failings in the trust’s procedures, prompting deputy NHS chief executive David Flory to remind all relevant health service executives of their duties regarding fire safety.

The fire at the Woodlands unit broke out in a patient’s room on October 26, 2011, just three months after it opened.

Mental health staff silenced or reset the fi re alarm eight times before finding the psychiatric patient responsible unconscious in a smokefilled room. They had set fire to the bed with a cigarette lighter. Firefi ghters had to force their way through locked doors to reach the patient.

A subsequent investigation by Suffolk Fire & Rescue Service (SFRS) found a failure to provide adequate training for staff, that there had been no fi re drills, and that problems identified in a previous ‘notice of deficiencies’ had not been properly addressed.

There would have been enough evidence to prosecute the trust responsible, Suffolk Mental Health Partnership Trust – but that body no longer exists, following its merger with the Norfolk and Waveney trust, and the successor body cannot be held criminally responsible.

The Department of Health has since corrected that loophole, so the default position is that criminal liabilities will be transferred to successor bodies.

In his letter, Flory told executives and trust board members that the SFRS report “identifi ed a catalogue of failings giving rise to the mismanagement of fi re safety across the organisation. There are lessons for the NHS to learn from the publication of the report by the FRS, as many of the areas of concern appear to be issues that are easily resolved”.

It continues: “In November 2012, London Fire Brigade served an Enforcement notice on a separate NHS Trust for similar failings. This level of apparent mismanagement and lack of governance of fi re safety issues gives rise to overall concerns about patient safety. Therefore, NHS Trust and NHS Foundation Trust Chief Executives, and Trust Boards are reminded of their duties under current fi re safety legislation – the Regulatory Reform (Fire Safety) Order 2005.

“Consequently, I would advise that immediate steps should be taken to review fi re safety across your organisation to ensure those duties are being met and that patient safety is not being compromised.”

The main findings of the SFRS report were that the trust failed:
• To suitably assess, monitor and supervise means for starting a fi re on the premises;
• To ensure employees with no authority, role, or relevant training are not allowed to access the fi re alarm control panel;
• To carry out a suitable fi re risk assessment before occupying the premises;
• To assess individual patients to evaluate their level of dependency in the event of evacuation, or the level of fi re risk they may pose to themselves and others;
• To ensure fi re exits were unlocked during a fire emergency;
• To provide employees with suitable information about their nominated duties, or appropriate training;
• To undertake practice fi re drills on wards;
• To provide an employee with suitable training or support for their nominated role, eg; the nomination of a ‘responsible person; without their knowledge;
• To ensure staff were familiar with the emergency fire action plan and that they received refresher fire safety training in the prescribed period, or premises-specifi c fi re safety training for their new workplace.

The fire service called the trust’s fire management arrangements “materially ineffective”, due to ineffective strategic management systems depending on delegated individuals to report concerns or issues to senior accountable managers, and a lack of monitoring or auditing of staff fire safety awareness, performance and training.

The report also found that staff fi re safety training, fi re practice drills, and the fire safety equipment testing and maintenance regime at the trust were being administered in such a way by the fi re safety manager and estates department team that the frontline personnel at the unit had little awareness of, or engagement with, the routine fi re safety activities and tasks in their workplace.

There was a lack of instruction, training and support for individuals in key fire safety related functions. In particular, staff (including line managers) had not been provided with suitable premises-specific training to inform them of the fi re risks and procedures in a newly opened building.

There was a lack of competency assessment or assurance and poor communication arrangements: while key fire safety information was available on the trust’s online ‘Smartline’ system and across a range of documents, its communication to staff was either non-existent or ineffective.

Norfolk and Suffolk NHS FT chair Maggie Wheeler said after the fire service’s report that since the new trust took over, it has “addressed every single one of the actions identifi ed by SFRS”.

She said: “At subsequent meetings regards Woodlands, the fire service has indicated they are satisfi ed with our progress and we have no outstanding notices against the unit. “Ways of working on the unit have changed considerably.”

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