Following an investigation into a fire at a hospital in October 2011, the local fire and rescue service (FRS) felt that there was sufficient evidence of inadequate fire safety governance to prosecute the NHS trust. However, between the accident and the publication of the FRS report into the incident, the trust merged with another trust and under the terms of the merger criminal liability did not transfer to the new organisation.

On 31 January 2013, David Flory, Deputy NHS Chief Executive, wrote to NHS chief executives annexing a summary of the main findings of the FRS report and reminding them of the duties owed by chief executives and trust boards under the Regulatory Reform (Fire Safety Order) 2005. He also makes it clear that the DH has "taken steps" to close the loophole to ensure that in the event of merger of NHS organisations, criminal liability will now transfer.

He recommends that immediate steps are taken to review fire safety to ensure that the duties under current fire legislation are being met and that patient safety is not compromised.

The main findings of the report are that there was:

  • A failure to assess, monitor and supervise the means for starting a fire
  • A failure to ensure that employees who are not authorised are not allowed to access the fire alarm control panel
  • A failure to carry out a suitable risk assessment before occupying the premises
  • A failure to assess individual patients to evaluate their level of dependency in the event of evacuation being necessary
  • A failure to review and revise the fire risk assessment
  • A failure to ensure exits were unlocked during an emergency
  • A failure to properly train employees with specified duties in the event of an emergency
  • A failure to undertake fire drills on wards
  • A failure to ensure staff are familiar with the emergency action plan
  • A failure to ensure staff renewed their safety training within the required period
  • A failure to ensure that staff received premises specific training when they started work in a new workplace.

The report concluded that the strategic management arrangements at the trust were materially ineffective, with there being ineffective systems in place that relied on individuals reporting concerns. There was no routine supervision of the fire management systems, ineffective monitoring and maintenance of staff safety training and frontline staff had little awareness of fire risks.

Of wider interest beyond the realms of fire safety is the comment in the report about poor communication. Although it was acknowledged that key fire safety information was on the trust’s intranet, its communication of that information to staff was ineffective or non-existent. There is absolutely no point in having a policy, of any description, whether it relates to fire procedures, or for that matter clinical procedures, unless you can demonstrate that efforts are made to effectively communicate that policy to the relevant staff.