Ipswich/Suffolk: Patient almost died as fire alarm was ignored eight times
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.
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.
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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.
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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.”