By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist
A version of this piece was first published by Open Democracy on 9 February 2018.
Coroners have been critical of two recent patient fire deaths at
Cambridgeshire and Peterborough NHS Foundation Trust and at Berkshire Healthcare NHS Foundation Trust , which are both mental health providers.
The 2008 Chase Farm Hospital fire of the locked, forensic psychiatric wards was a reminder of the potential lethality of fire in psychiatric hospital settings.
The 2008 Chase Farm Hospital fire
The 2011 fire at Woodlands psychiatric unit at Ipswich Hospital resulted in a damning fire safety report on system failures, which resulted in the alarm being ignored eight times. Norfolk and Suffolk NHS Foundation trust escaped criminal prosecution only because of a legal loophole. The then Chief Executive of the NHS Trust Development Authority acknowledged this serious mismanagement and promised that standards would be tightened up.
Mental health services must deal with the special risks of fires caused by patients who are disorganised by illness, or people who set fires deliberately. The government acknowledges this risk in its fire safety guidance for the NHS.
Vigilance and proactive care are needed. But strain on under-funded mental health services result in understaffing, chronic over-occupancy, escalating acuity and failures of clinical observation. The latter have been cited repeatedly by coroner’s warnings as factors in avoidable deaths. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness advised in 2015 that there had been 124 in-patient suicides under observation between 1st January 2006 and 31st December 2012 in the UK.
There are also well-known fire safety problems at some PFI hospitals. After the Grenfell Tower fire, the presence of flammable cladding – banned for some uses in the USA – in NHS hospitals was exposed.
Risk assessment is tangled up with financial imperatives. Some of the flammable cladding in hospitals was left in situ because it was considered too costly to remove.
The general pressure on trusts was also reflected in the fact that some delayed in implementing fire checks ordered by NHS Improvement after the Grenfell fire.
Risk is also posed by an ever-mounting backlog of repairs and maintenance work in our hospitals, as NHS trusts struggle to make ends meet. This includes fire prevention work.
Fast staff reaction in the 2008 Royal Marsden Hospital fire prevented deaths, but there was major damage.
Worryingly, subsequent enquiries by BBC File on Four revealed that Fire Services had been driven to serving enforcement notices against NHS trusts. A glance at the enforcement register shows that this continues despite promises of improvement.
How much fire risk is tolerable, in hospitals with accelerant medical gases and infirm or detained evacuees?
The investigation report on the London Underground fire at Kings Cross, which claimed 31 lives, criticised London Underground’s complacent culture and argued:
“A mass passenger transport service cannot tolerate the concept of an acceptable level of fire hazard”
NHS Digital’s data on fires in mental health trusts
Data from routine notification of estate fires by NHS trusts to NHS Digital shows that there were 1701 and 1462 fires in all trusts in 2015/16 and 2016/17 respectively. Mental health trusts accounted for 1138 (67%) fires in 2015/16 and 895 (61%) fires 2016/17 respectively.
Over these two years, 88 people were injured in all NHS trust fires, with 64 of these people being injured in fires related to mental health trusts. There were four deaths in trusts fires, three accounted for by mental health trusts.
Data from the National Confidential Inquiry into Suicide and Homicide by people with mental illness (NCISH)
A request to NCISH under the Freedom of Information Act has revealed a total of 259 patient suicides and 14 inpatient suicides by burning over the ten years between 2005 and 2015.
FOI data from NCISH also suggests that roughly a fifth of suicides by burning are due to patient suicides by burning.
Underlying these deaths, there will be many more injuries and near misses.
Sprinklers in mental health trusts
The Chief Fire Officers Association promotes the use of sprinklers. The London Fire Brigade has advocated for the use of sprinklers in healthcare premises. As the London Fire Commissioner has explained,
“Sprinklers are the only fire safety system that detects a fire, suppresses a fire and raises the alarm. They save lives and protect property and they are especially important where there are vulnerable residents who would find it difficult to escape”
The government’s fire standards for the NHS briefly mention but do not commit to installation of sprinklers. The guidance also repeatedly states that where sprinklers are used, other fire prevention measures may be reduced for cost-effectiveness. 1
Since Grenfell, the government has been pressed on the adequacy of its regulations for sprinklers in hospitals, and whether sprinklers are required in all hospitals. Last month, the Minister of State advised that all guidance was under review.
The exact distribution of sprinklers across the NHS estate is uncertain. The data is not collected centrally by NHS Digital. Expectations do not appear high. A fire safety policy by Northumberland Tyne and Wear NHS Foundation Trust states:
Recent FOI data reportedly showed that thousands of multi-storey buildings, including hospitals, do not have sprinklers.
Even some new builds such as Forth Valley Royal Hospital have not included sprinklers. The troubled Cumberland Infirmary PFI development will not have sprinklers fully installed until 2020. Corporate documents and FOI releases by some NHS organisations, for example by Sheffield Teaching Hospitals NHS Foundation Trust, NHS Grampian and NHS Lothian show patchy sprinkler coverage.
It has also been alleged that some hospitals, for example The National Children’s Hospital in Dublin, may be built just below the limit of 30m to avoid legal obligations to fit sprinklers.
Moreover, working on the ‘acceptable hazard’ principle, where one safety precaution is installed, others may be trimmed. For example, one architect reported that on one Scottish NHS PFI project, because sprinklers were specified, there was corner cutting on other safety features:
However, the deadliness of fire was shown last week by a fire in a Korean hospital with no sprinklers, that killed 37 people.
This revealed that almost no mental health trusts have sprinklers. Three trusts had sprinklers in 10% of their inpatient areas, and in one of these trusts this was only because a retrofit took place after a contribution by the local Fire service. Two other trusts trust leased four community properties equipped with sprinklers, but none of their own properties had sprinklers.
Some trusts stressed that installing sprinklers was “not a requirement under current legislation”. However, legality is a moot point after Grenfell and given the controversy about UK fire safety standards.
East London NHS Foundation Trust, rated ‘Outstanding’ and praised the Care Quality Commission for its learning culture was one of the trusts which failed to respond to the FOI at all. NHS Digital data shows that there was a fire related death at East London NHS Foundation Trust in 2016/17 and that a total of seven people were injured in fires in 2015/16 and 2016/17.
The 49 trusts which responded to the FOI request accounted for a total of 1800 fires over 2015/16 and 2016/17, at least 790 of which were deliberately caused and at least 801 of which were caused by patients. 2
Conservatively, at least 1000 of the fires occurred on inpatient units, some in rooms that might potentially be locked or barricaded such as patients’ bedrooms and bathrooms.
One mental health trust acknowledged that there is risk inherent in all fires: “they all carry a potential risk of harm”, whereas another claimed that all fires on its wards were “minor in the sense that items burnt were limited to paper and clothing”. Better data is needed on the seriousness of the fires.
Questions arise about whether this level of risk management in mental health trusts is acceptable, and whether it is valid to trim back on failsafes. For example, relying on fire alarms instead of sprinklers. This was a justification given by Mersey Care NHS Foundation Trust for not having sprinklers.
In particular, the absence of sprinklers in patients’ bedrooms and bathrooms bears further debate, because such areas may not be accessible quickly enough in an emergency. Heather Loveridge died as a result of a fire in a ward toilet and Sarah-Jane Williams died as a result of a fire in a ward bedroom at trusts which had no sprinklers.
There are also unanswered questions about sources of ignition on mental health trust wards despite the NHS smoking ban. How many ward fires set by patients due to failures to search and remove lighters, reflecting the acute strain on services?
I asked NHS Improvement, NHSTDA’s successor body, if it was doing any work on the special needs of mental health patients with respect to fire safety.
NHS Improvement referred me to the Department of Health
NHS Improvement referred me to the Department of Health and Social Care, based on its impression that the Department had undertaken a 10 year review. This was followed by a hasty retraction, and then a denial from the Department of Health and Social Care itself that it held such data. The Department finally suggested that I ask ask NHS Improvement for information.
This bureaucratic merry-go-round suggests that either little thought has been given to this matter, or worse, that pass-the-parcel is being played with embarrassing truths whilst mental health patients remain insufficiently protected.
The Department of Health and Social Care’s own fire guidance states that it is important to demonstrate “due diligence and effective governance” and recommends that the “performance of the fire safety management system is periodically audited and assessed against the organisation’s fire safety objectives”
The Department should follow its own advice, ensure better oversight and rectify any unwarranted risks to which mental health patients are currently exposed. If risk continues to be tolerated at a systemic level, the government should at least transparently provide justification for this.
UPDATE 17 FEBRUARY 2018
‘Outstanding’ East London NHS London Foundation Trust, which had a fire death in 2016/17 and seven people injured in fires in 2015/16 & 2016/17, belatedly responded to my FOI request of 29 October 2017 on 15 February 2018. Outstandingly, ELFT pretended in its response that the FOI clock started on 29 January 2018, when this was actually the date of a reminder. Most importantly, ELFT admitted that it had no sprinklers.
1 The Department of Health and Social Care’s fire safety guidance states:
“5.68 With the exception of buildings over 30 m in height, the guidance in this document does not require the installation of sprinklers in patient care areas of healthcare buildings. However, the design team is expected to consider the advantages that might be gained by installing life-safety sprinklers throughout the building or to specific areas. Where specific hazards are identified in the building, it may be more appropriate to consider the application of an alternative fire suppression system, such as high pressure water mist technologies.”
Throughout the guidance, it is stated that where sprinklers are used, other fire prevention measures may be reduced, and this explicitly linked to saving money. For example:
“5.85 In those parts of healthcare buildings where sprinkler systems are provided, the effect of sprinklers on the overall package of fire precautions has to be considered to ensure that a cost-effective fire safety strategy is provided. Where sprinklers are installed in healthcare premises in accordance with the above guidance, some of the requirements of this document may be modified to take account of the effect of sprinkler operation at an early stage of fire development.”
“5.86 Where sprinklers are installed, the guidance may be modified subject to a suitable and sufficient risk assessment being undertaken and the information being recorded in the fire safety manual. Examples include:
- progressive horizontal evacuation (paragraphs 3.6–3.15);
- glazing in sub-compartment walls (paragraphs 5.23–5.25);
- elements of structure (paragraphs 5.1– 5.7 and 5.14–5.15);
- compartmentation (paragraphs 5.8– 5.13);
- fire hazard rooms and areas (paragraphs 5.40–5.44);
- external fire spread (paragraphs 6.5– 6.15);
- number and location of fire-fighting shafts (paragraphs 7.11 and 7.13).”
“3.12 Where sprinklers are installed, the fire resistance of the compartment walls may be reduced to 30 minutes (integrity and insulation)”
“5.15 Where sprinklers are installed throughout the whole building, the requirement for elements of structure and compartment walls to be constructed of materials of limited combustibility does not apply”
“5.25 Where sprinklers are fitted, there is no limit on the use of glazed screens that provide a minimum period of fire resistance of 30 minutes (integrity only), provided the glass is not of the type referred to as “modified toughened”
“5.43 Where sprinklers are installed, the need to enclose fire hazard rooms in fire-resisting construction should be risk-assessed.”
2 Both data from NHS Digital and the FOI material from trusts should be viewed with caution. It became clear that some mental health trusts are reporting all fires involving patients to NHS Digital, and not just fires on their own premises. One trust claimed that the NHS Digital figures on its fires was greatly inflated because they included false alarms and not just actual fires. Conversely, some NHS Digital data was placed in doubt after a few apparent zero returns were directly queried with the trusts in question, who gave conflicting data.
Some mental health trusts volunteered that all or most their arsons were carried out by patients. Fires were also most frequently located in inpatient areas.
By comparison, FOI requests to three acute trusts that had also reported high numbers of fires showed a much lower proportion of fires that were caused deliberately or by patients: there were only 4 deliberately caused fires and three fires caused by patients out of a total of 178 fires over the two years.
Rough though the quality of this data is, the differences do support received wisdom that the risk of arson by patients is higher in mental health trusts, and that unsurprisingly, many of the fires are set on inpatient psychiatric wards. This might be expected as the most unwell people will be found on the wards.