Ipswich/Suffolk: Patient almost died as fire alarm was ignored eight times
12:36 20 December 2012
Mental health staff ignored a fire alarm EIGHT times before discovering a psychiatric patient was lying unconscious in a smoke-filled room, after setting light to the bed with a cigarette lighter.
We have taken action – mental health bosses
MAGGIE Wheeler, chair of Norfolk and Suffolk NHS Foundation Trust (NSFT) said they have taken the fire service’s findings “extremely seriously”, acting immediately to make changes.
“This was a potentially life-threatening incident and we are taking Suffolk Fire and Rescue Service’s report into their findings extremely seriously,” she said.
“When this incident happened, Woodlands was managed by the former Suffolk Mental Health Partnership NHS Trust and we are aware there were patient safety issues within the organisation which was dissolved at the end of December 2011.
“Part of the former trusts shortcomings was a lack of organisational responsibility for this important area, including adequate fire training for staff and fire procedures.
“Since NSFT took over, we have addressed every single one of the actions identified by SFRS.
“At subsequent meetings regards Woodlands, the fire service has indicated they are satisfied with our progress and we have no outstanding notices against the unit.
“We take patient safety and fire safety extremely seriously at NSFT, and are grateful for the thorough investigation carried out by SFRS, and for the work we have been doing jointly to address safety issues.
“We have not waited until this report was published to address the issues raised – staff have been working on improvements since the fire itself, and we have made considerable changes since NSFT took over the running of the unit in January.
“We are confident that 14 months on, ways of working on the unit have changed considerably, and we will continue to work closely with SFRS in our common objective of ensuring all our property remains fully compliant with fire safety regulations.”
When firefighters arrived at Woodlands Unit on the Ipswich Hospital site at Heath Road, they had to force their way through locked fire doors to reach the young patient dragging them from the room to resuscitate them.
In a damning report, seen by The Star, Suffolk Fire and Rescue Service (SFRS) state officers have gathered enough evidence to support prosecution of the Suffolk Mental Health Partnership Trust (SMHPT) for a range of offences.
But due to the merger of SMHPT with the Norfolk and Waveney trust on January 1 this year, the body no longer exists.
A gap in the law and the way the transfer was handled by the Department of Health means the newly established Norfolk and Suffolk NHS Foundation Trust (NSFT) cannot be held criminally responsible.
Chair of the NSFT, Maggie Wheeler told The Star by working closely with SFRS and implementing a change of culture and management since the merger, a raft of fire safety changes have been introduced.
On October 26, 2011 the fire alarm sounded at the Woodlands unit at 3.20pm indicating a blaze in a bedroom.
CCTV footage and fire alarm logs examined by SFRS during their investigations show on eight occasions a member of staff either silenced or reset the alarm.
For more than five minutes there was no attempt to investigate the cause of the alarm.
Chief fire officer at SFRS, Andy Fry told The Star: “As a consequence of that delay, when staff did go to the room, the patient was unresponsive. “The fire had developed to the extent that when staff went into the room the smoke was so thick they were unable to see the patient, let alone bring them out of the room.
“The patient was then left in the smoke-filled bedroom until firefighters rescued him at 3.45pm – some 25 minutes after the fire had first been detected.”
The failings found during the SFRS investigation include:
n A failure to provide adequate fire safety training for staff at the Woodlands unit
n No safety drills had been carried out since the unit had been opened and occupied
n A previously issued ‘Notice of Deficiencies’ had not been fully addressed
Leigh Fleming, commercial director at NSFT said because Poppy Ward is not a locked ward, patients can come and go and are not routinely searched.
“Subsequent to this we have revised our smoke policy reminding staff there are electronic lighters in the courtyard so there is less need for patients to have lighters and matches,” she said.
“This patient was not in the high-risk category. Nothing in the patients risk assessment led us to believe they were going to start a fire.”
She said since the formation of NSFT 98 per cent of staff had received fire training.
Other improvements made since the fire include a full-scale evacuation programme at Woodlands, restatement of responsibilities for designated fire officers and a review of fire systems, doors and their security.
Ms Wheeler added: “We are looking at the lessons we can learn and apply to units across Norfolk and Suffolk.”
While accepting a high number of staff from SMHPT were still working for NSFT, Ms Wheeler said the senior management team were “wholly new” and the “culture and management of the organisation has changed”.
Mr Fry added: “The report catalogues a series of failings at many levels of the organisation and mismanagement which led to a vulnerable person being seriously injured and members of staff, and other patients, being placed at serious and imminent risk.
“It is extremely fortunate that the patient involved did not lose their life.
“Because of the way in which the Department of Health subsequently enabled the trust to be acquired by another, we have been unable to take a prosecution against the organisation formed by the acquisition - a problem we now believe to have been addressed by the Department. Despite this, it is important that the lessons available from the Woodlands incident are properly learnt.”
A spokeswoman for the Department of Health said: “The government has taken steps to ensure that, for all future dissolutions and mergers of NHS Trusts, the default position is that criminal liabilities will transfer to the successor body.”