IN the aftermath of a tragedy, where the loss of life could have been prevented, those who mourn are overwhelmed by unanswered questions.
The Fatal Accident Inquiry into the deaths of 14 elderly residents at Rosepark Care Home in Uddingston has been harrowing for their relatives, the staff who cared for them and the fire fighters who attempted to rescue them from the burning building seven years ago. Its findings, however, provide answers to the questions that must be asked if similar disasters are to be avoided.
Sheriff Principal Brian Lockhart’s detailed inquiry has uncovered a catalogue of failures that must prompt all those providing residential care to re-examine their own risk assessments and safety procedures.
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Like most such events, it is clear, with the benefit of hindsight, that Rosepark was an accident waiting to happen.
Its catastrophic scale, however, was due to a series of omissions, lax practice and misunderstandings, on the part of regulatory bodies as well as the owners of the home, which combined with fatal consequences.
The abject failure by Thomas Balmer, the owner of the home, to address the risk of a fire breaking out or how to evacuate elderly residents is genuinely shocking.
A fire would be problematic enough during the day but the prospect of getting frail, confused and disabled people out of bed in the middle of the night is so fraught with difficulty that it must be an essential part of staff training.
Yet not one of the four members of staff on duty in the early hours of January 31, 2004, had ever been on a fire drill.
They and the fire fighters were further hampered by wrong information on the building’s fire zones which had never been put to the test.
The professionals on the scene were forced to blunder their way through a situation in which the difference between life and death depends on clear heads and competence.
The owners of the home must carry the main burden of responsibility but the omission of fire safety inspections by both Lanarkshire Health Board and the Care Commission on the wrong assumption that this was the duty of the fire and rescue service amounts to a serious failure to ask basic questions.
The sorrow they felt by the families of those who died will have been compounded by the emergence of the signal failure by individuals at every level to make residents’ safety the priority.
The only comfort they can salvage is that lessons have already been, and will continue to be, learned.
The inspection regime must ensure that is the case in every home that claims to care.