Donwell House Care Home Fire Investigation, Fire Safety - - PowerPoint PPT Presentation

Donwell House Care Home

Fire Investigation, Fire Safety Investigation, Prosecution & Legal Support

Sensitive Material

Incident Details

• Donwell House Care Home, Donwell Village

Centre, Washington, 2 storey, 63 residents

• Formally 2 separate homes
• Provides Nursing and Residential Care
• Day Centre Attached

13th September 2014

• 18:20 Local Fire Crews received a

Malicious Fire Call

Premises Plan

• Shift Change at 20:00 –Still fully staffed (-

1)

• Teatime
• Residents Rooms (locking)
• Staff Break

Fire

• Approximately 18:20 Fire Alarm sounds
• Staff Actions

– Location – Fire Alarm Zones – Call for help (bathing) – Evacuation

• Fire Service Control mobilises 3 pumps
• Hebburn and Birtley
• Staff carry out PHE and make a discover that
• ne person is unaccounted for

• Additional pump mobilised from Malicious

call

On Arrival

• Smoke from Roof
• Lots of people (pub)
• Evacuation in progress
• Resident at window
• Fire Service access
• Fire Service actions

Lady left in room Room of Origin

Open door

Nursing Wing

Adding value

Post Fire Audit:

• Monday 15th Sept 2014
• Post Fire Audit Conducted
• Building performed
• Fire Strategy performed

– Management – Procedures

• Engagement
• Enforcement

Decide Whether to Investigate

• Has an Offence been committed?
• Offences Article 32 – (1) It is an offence for any

responsible person or any other person mentioned in Article 5 (3) to:- – (a) Fail to comply with any requirement or prohibition imposed by Articles 8 – 22 and 38 (fire safety duties) where that failure places one or more relevant persons at risk of death or serious injury in case of fire.

Considerations of an Investigation

• Establish Investigation team;

– Lead Investigator – Investigation Support – Officer Case Management Team Officer – Support Officers

• Gather evidence of failings

– Witness statements – Photos – Documentation

• Fire Risk Assessment
• Maintenance Records
• Training Records
• Company Policies and Procedures

Company Structure

• Bondcare – Company created when Southern Cross Group went

into administration. Bondcare took over 18 homes with the group.

• Care Living – Approximately May 2014 started to provide

management support to Donwell House, policies and procedure, book keeping and payroll.

• Shaftesbury Care Group Limited – This company took over

Donwell House and 7 other Bondcare properties in 2015. Care Living still provided management support.

• The same Managing Director for all 3 companies

Investigation

Interview Under Caution with Company Solicitor Present – Manager 21st October 2014 – Deputy Manager 20th October 2014 – Maintenance 20th October 2014 – Regional Manager 2nd December 2014 – Company Director as spokesperson for the company (Responsible Person) Scheduled for 17th December 2014, interview took place on the 13th July 2015

Investigation outcome

• Step 1- Is the decision to continue the investigation?

– Case review meeting

– Step 2 - Is the Investigation concluded?

– No Further Action – Simple Caution

• Step 3 - Is the decision to take forward to prosecution?

– Case bundle (Legal Services)

• Step 4 - Have all interested parties been informed of the outcome?

– Responsible Person(s) – Other stakeholders, e.g. Environmental Health – Legal Services – Media Resources e.g. communication – Other agencies.

Tyne and Wear Fire Authority v Shaftesbury Care Group Limited Indictments Laid to Court

INDICTMENT (Count 1) Failing to comply with Article 8(1) of The Order, read together with Article 4(1)(a) of the Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire PARTICULARS OF OFFENCE On the 13th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, the door to Bedroom 29 was wedged open, enabling thereby smoke and flames to pass into the means of escape.

INDICTMENT (Count 2) Failing to comply with Article 8(1) of The Order, read together with Article 4(1)(a) of the Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order. PARTICULARS OF OFFENCE On the 13th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, the door to Bedroom 30, which should have been closed immediately after access to and egress from the said room, so as to be a barrier to the spread of fire on the Premises, was left

• pen, enabling thereby smoke and flames to spread to the said bedroom.

INDICTMENT (Count 3) Failing to comply with Article 17(1) of the Order, thereby placing one or more relevant persons at risk

• f death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order.

PARTICULARS OF OFFENCE Between the 11th day of September 2013 and the 10th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, fourteen fire extinguishers were not maintained in an efficient state, in efficient working

• rder and in good repair.

INDICTMENT (Count 4) Failing to comply with Article 13(1) (a) of the Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order. PARTICULARS OF OFFENCE On the 13th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, The Premises were not equipped with appropriate means for detecting fire and giving warning in the event of fire in The Premises.

INDICTMENT (Count 5) Failing to comply with Article 9(1) of the Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order. PARTICULARS OF OFFENCE Between the 12th day of May 2014 and 13th day of September 2014, at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, the fire risk assessment for The Premises which was in force between 12th May 2014 and 13th September 2014, did not include a suitable and sufficient assessment of the risks to relevant persons from 14 defective fire extinguishers in the Premises, and from the locking of their doors by certain residents thereby adversely affecting their evacuation in the event of fire

INDICTMENT (Count 6) – Not Taken Forward Failing to comply with Article 21(1)(b)(i) of The Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order. PARTICULARS OF OFFENCE On or about the 15th day of June 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, an employee, George Illingworth, was not provided with adequate safety training by being familiarised with the fire risk assessment for the Premises, at the time when he was exposed to new or increased risks because of his being given a change of responsibilities within the undertaking at The Premises.

INDICTMENT (Count 7) – Not Taken Forward Failing to comply with Article 11(1) of The Order, thereby placing one or more relevant persons at risk

• f death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order.

PARTICULARS OF OFFENCE On the 13th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, appropriate arrangements had not been made and given effect to for the effective planning, organisation, control, monitoring and review of the preventive and protective measures as the log book for The Premises lacked the necessary sheet for identifying deficiencies in fire precautions in The Premises.

INDICTMENT (Count 8) – Not taken Forward Failing to comply with Article 15(1)(a) of The Order, thereby placing one or more relevant persons at risk of death or serious injury in case of fire, contrary to Article 32(1)(a) of The Order. PARTICULARS OF OFFENCE On the 13th day of September 2014 at the premises known as the Donwell House Care Centre, Wellgarth Road, Washington Tyne & Wear NE37 1EE (“The Premises)”, appropriate procedures relating to safety drills, to be followed in the event of serious and imminent danger to relevant persons, had not been established.

Hearings

Sunderland Magistrates Court - 13th January 2016 During the initial case hearing, Shaftesbury Care Group Limited offered no plea and the case was referred to Newcastle Crown Court. Newcastle Crown Court - On the 10th February 2016, the case was heard at Newcastle Crown Court, during which Shaftesbury Care Group Limited pleaded guilty to five offences of the eight

• ffences identified and not guilty to three remaining offences. The Judge took the decision that due to

the severity of the offences the case was to be adjourned for a sentencing hearing on the 22nd March 2016. Newcastle Crown Court (Moat House) - On 22nd March the sentencing hearing was heard at Newcastle Crown Court with TWFRA being represented by David Claxton QC of Red Lion Chambers, providing a case summary of our investigation.

VERDICT

Shaftesbury Care Group Limited Pleaded Guilty to 5 Counts.

• Failure to comply with Article 8 (when read with Article 4)

– Wedging of door to bedroom 29

• Failure to comply with Article 8 (when read with Article 4)

– Wedging of door to bedroom 30

• Failure to comply with Article 17

– 14 Fire Extinguishers not maintained in an effective state

• Failure to comply with Article 13

– Not providing an appropriate means of detection and giving warning

• Failure to comply with Article 9

– FRA did not identify the 14 Fire Extinguishers or the risks associated with residents being able to lock their doors

• Using the recently published Sentencing Guidelines, The Recorder, David Wilby QC,

who considered the case, awarded Shaftesbury Care Group Limited the full 33% discount for pleading guilty at the earliest opportunity reducing their total fine from £570,000 to £380,000.

• In addition, he ordered the defendant company to pay full costs at £29,222. Costs to

be paid in full within 56 days. In view of the size of the fine he allowed the company to pay in two instalments the first £180,000 by 1st April 2017, the remaining £200,000 by the 1st April 2018.

• The fines also took into consideration the size and turnover of the company of just
• ver £10 million and profits of over £2 million for the last two years

Newcastle Crown Court 22 March 2016: Sentencing Hearing £380,000 /£29,222

• Count 1&2 Doors Wedged Open

– Room 29 £100,000 – Room 30 £80,000

• Count 3 Fire Extinguishers

– Fourteen defective fire extinguishers £50k

• Count 4 Means for Detecting Fire

– Zoning Issues – Repetition of numbering £50,000

• Count 5 Risk Assessment (Article 9)

– Locks on residents doors – Fourteen defective fire extinguishers – Provision of Door Guards. £100,000

Fines totalled £570,000 discounted by 33%