HC-One Limited fined £500,000 following Arcadia Gardens Care Home fire

On 25 March 2017 at around 4.25 pm, a fire broke out at the Care Home in Glasgow. Carol Hughes was a resident there. Having been rescued by firefighters from the Scottish Fire and Rescue Service, Hughes was taken to the Glasgow Royal infirmary. On that same day at 9.20 pm, she succumbed to the injuries that had been sustained as a result of the fire.

On admission to hospital, Hughes was found to have airway compromise, albeit that she was able to maintain her own airway. She also had 65%-75% burns. Due to the fact that her survival seemed very unlikely, she was treated palliatively in the time immediately before she died. A post-mortem examination some days later recorded her death as being due to severe burns and the inhalation of smoke.

The Arcadia Gardens Care Home is a residential community located in the East End of Glasgow. It’s purpose-built and provides general nursing and residential care for those suffering from physical and mental disabilities.

At the time of this tragic death, there were 72 en suite single bedrooms and a staff of around 75. The main residential part of the building was a single-storey construction divided into three internally linked units, each of them catering for 24 residents. There was also a laundry, kitchen, dining room, offices, TV rooms and several communal areas as well as an outdoor communal garden area. At the time of the fire, the garden area was the sole designated smoking area.

Fire alarm system

The fire alarm system divided the care home into 12 zones, each divided by fire doors. Room 51, where Hughes was resident, is in Zone 12. The kitchen and laundry are adjacent in Zone 6.

When the fire alarm sounded, nominated staff members from the facility made their way to the main fire alarm control panel that was located on the wall in the main reception area in order to establish the cause of the fire alarm and to further establish the part of the building in which the alarm had operated.

In the event of a fire, the fire detection alarm should indicate in which zone the fire is located by means of a red light. The system showed Zone 6 as the location of the fire alarm activation. This corresponded with the kitchen and laundry area on the zone plan located next to the fire alarm panel.

The kitchen staff who worked in Zone 6 initially evacuated the building as this was what they were instructed to do. Following dialogue with the manager, they re-entered the building in order to investigate the fire alarm activation. In fact, no fire was discovered within Zone 6.

Following a period of time, members of staff saw smoke building up beyond the cross-corridor doors leading from Zone 6 to residents’ rooms. Upon further investigation, it was discovered that the smoke was coming from Room 51 occupied by Carol Hughes. Due to the level of smoke build-up within the corridor, staff were not able to access Hughes’ room to assist with evacuating her from the building.

At 4.50 pm, Hughes was rescued by Scottish Fire Rescue Service personnel and taken by ambulance to the Glasgow Royal Infirmary.

The subsequent Scottish Fire and Rescue Service investigation established that the fire had originated within Room 51, most likely among bedlinen or clothing worn by Hughes. The fire had spread to bedding materials and the air mattress of the bed. A lighter and e-cigarette was found on the bed. A second lighter was found on the floor close by the bed. Those items were the only viable ignition sources identified in the area where this fire started.

The conclusion of the investigation report was that: “This fire was accidental in nature and [was] a result of the careless disposal and/or use of smokers’ materials on or among the deceased’s clothing or bedding.”

System review

Following this incident, an independent inspection of the fire alarm system was carried out by Mitie Fire and Security. The company established that the zone chart was found to be inaccurate insofar as Room 51 was displayed on the indicator panel as part of Zone 6 when the chart showed this room in Zone 12.

Had the correct zone and room been identified by the fire detection system, members of staff would have been able to attend the location of the fire sooner. However, it cannot be said that the tragic loss of Hughes’ life can be attributed to any delay which occurred in attendance at her room.

The Arcadia Gardens Care Home came into the ownership of the HC-One Group in November 2011, at which time the Group became the duty holder for the premises. The company is one of the largest care home businesses in the UK with over 250 care homes under its umbrella and taking care of people with dementia and those who need nursing, residential and specialist care.

The company pleaded guilty to a contravention of Section 3(1) and 33(1)(a) of the Health and Safety at Work, etc. Act 1974.

Specifically, the company has admitted that, first, it had failed to undertake an adequate review of the care plan pertaining to Carol Hughes once she had become bedbound and, in particular, failed to suitably and sufficiently assess the risks to her health and safety to which she was exposed by having access to smoking materials whilst bedbound.

Second, the company had failed to maintain the fire alarm detection system in an efficient state, in efficient working order and in good repair, in that the system, when activated by detector, did not identify accurately the location of the activation. The company accepts that, as a result of the initial failure, and while she was bedbound with access to smoking materials, a fire broke out in Carol Hughes’ clothing, bedlinen or similar material, which then caused her to suffer severe burns and smoke inhalation from which she died.

Separately, the company accepts that there was a delay in identifying the location of that fire due to the defect in the fire detection system.