Hospital building works fire

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• No risk assessment was carried out on the effect of the works on the old ward before they started.
• Fire doors were removed and replaced by plastic sheeting, which removed a fire control and let smoke and fire spread.
• The corridor between the buildings was opened up without protecting the escape routes of the old ward.
• Emergency procedures were not amended for the changes, as the plan was four years old.
• Staff and patients were not told about the changes or the risks.
• The contractor's hot work was not separated from the occupied ward, and there was no segregation of the work area.
• Smoke detectors were covered with the project manager's agreement, so a control was removed without assessing the risk.
• The project manager had no health and safety competence and was the only link with Summit.
• There was no review of the change during the works, even after the small fire in month 9.
• The contractor was chosen for speed rather than for safety competence.
• Staff on the ward were not involved or consulted about the work.
• Night staff and agency staff were not trained in the changed arrangements.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• The contractor was selected because it offered the shortest time, with no check of competence or safety record.
• Riverside has no safety competent person coordinating with Summit.
• Summit's hot work permit system was separate, and nobody at Riverside checked the permits.
• There was no joint planning between Riverside and Summit on shared risks such as fire.
• The contractor's workers were not given a site induction that covered the hospital fire arrangements.
• Riverside did not monitor the contractor's work, even after reports of hot work sparks.
• A small fire in month 9 was not reported to the HD, so management could not act.
• Both organisations share the workplace and have duties to cooperate, which was not done.
• Detectors were covered at the contractor's request without safeguards such as a fire watch.
• No method statements or risk assessments were requested or reviewed for the cutting and welding.
• Summit's sparks fell through a gap and no precautions such as fire blankets or watch after work were required.
• The contract focused on time and cost and did not specify safety requirements.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• The evacuation plan is four years old and has not been updated for the building works.
• Five night staff cannot realistically evacuate 28 patients, many of whom cannot walk, so the plan was not realistic.
• Night staff and agency nurses have never taken part in a fire drill.
• Day staff drills are held only once a year and the results have not been reviewed.
• Fire doors were wedged open, which allowed smoke into the ward.
• Detectors were covered, so there was no early warning.
• A manual call point was hidden by a notice board, so the alarm was raised by shouting.
• A porter sounded the siren four minutes late, which shows nobody knew who was responsible for raising the alarm.
• There are no fire marshals or wardens with defined roles.
• There was no personal emergency evacuation plan for patients who cannot walk, and no evacuation aids were mentioned.
• Staff were put at risk when carrying patients, and a nurse was injured.
• Fire fighters arrived 14 minutes after the call, so the hospital should have planned for a longer response time.
• There was no roll call of patients and staff after the evacuation.
• The internal audit had recommended drills and fire door inspections, but nothing was done.

Marks counted: 0 of 14

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Managers ask who was at fault after every incident, which creates a blame culture.
• Two staff who reported near misses were warned, which punishes reporting.
• Reports are not acted on, as the document shows no action for most of them, so staff see no point.
• The HD saw the audit as a paperwork exercise, which sets the attitude for the organisation.
• The safety committee meets only once a year and consultants do not attend.
• Improve by using a just culture that looks for system causes rather than blame.
• Improve by giving feedback to staff on what was done after each report.
• Improve by asking top management to show commitment, for example by reviewing reports regularly.
• Improve by training managers to investigate without blaming.
• Improve by consulting staff through a committee that meets often and includes all groups.

Marks counted: 0 of 10

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Organisational: five night staff for 28 patients is a low staffing level.
• Organisational: night shifts and extra day shifts cause fatigue, as seen when a nurse collapsed in month 5.
• Organisational: no drills for night staff and agency nurses, so training was missing.
• Organisational: the HD and managers did not treat safety as a priority, and the culture is of blame.
• Organisational: communication about the building works did not reach the ward staff.
• Job: wedged fire doors and a hidden call point made the task of raising the alarm and containing smoke harder.
• Job: patients who cannot walk make moving them a heavy and complex task for few staff.
• Job: smoke reduced visibility and added stress to an already demanding task.
• Job: procedures had not been updated for the changed building, so they were unclear.
• Individual: night staff lacked training, so they did not know what to do first.
• Individual: fatigue reduces reaction speed and decision making.
• Individual: staff gave priority to patients, and some took risks such as carrying a patient alone.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• An audit is a systematic, independent and documented check of how far the management system meets its criteria.
• An audit looks at the system as a whole and can find failures such as the lack of drills before an incident.
• An audit gives assurance to management, patients and regulators.
• An audit gives organisational learning that can improve the system.
• The audit report found the fire door, drill and building works problems that later caused harm.
• The HD should have made an action plan with owners and dates.
• Top management should have reviewed the report and tracked the actions.
• The findings should have been shared with managers and the safety committee.
• A follow-up audit or inspection should check that actions were carried out.
• An external audit could add independence and fresh ideas, though it costs more.
• An audit differs from an inspection because it examines arrangements and records, not only physical conditions.
• Audit findings should feed the management review so that top management can improve the system.

Marks counted: 0 of 12

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• The level of investigation should be high because of the number of injured people and the potential for harm.
• Form a team that includes a senior manager, a competent investigator, staff representatives and an expert on fire.
• Gather information: the scene, photographs, witness statements from night staff, the porter, Summit workers and fire fighters.
• Collect documents: the hot work permits, evacuation plan, drill records, audit report and incident log.
• Preserve evidence such as the detectors, fire doors and the cutting equipment.
• Analyse the information to find what happened and the sequence of events.
• Identify immediate causes such as sparks igniting insulation and detectors covered.
• Identify underlying causes such as weak contractor control, no change management and the blame culture.
• Identify human factors including fatigue and low staffing at night.
• Identify risk control measures, for example new fire doors, drills and a competent coordinator.
• Set up an action plan and check that it is carried out.
• Report to the enforcement agency and insurers following national law.
• Communicate the findings to staff to help restore trust.
• Avoid blaming individuals and look for causes that can be fixed by management.

Marks counted: 0 of 14

Tick each point that your answer made clearly and only once. Points here are this site's own. A real examiner may accept other valid points.

• Top management sets the direction and shows commitment, which the HD did not do by dismissing the audit.
• Top management provides resources, including night staffing, drills and safe equipment.
• Top management defines roles and responsibilities, which are missing for the alarm and for contractor liaison.
• Top management should appoint a senior person with specific responsibility for health and safety.
• Top management should appoint competent people inside or outside the hospital to help meet its duties.
• Top management should review health and safety performance, which was not done after the audit.
• Top management and Summit must cooperate on shared risks, as organisations sharing a workplace.
• Managers organise the work and make sure arrangements such as fire door control are followed.
• Supervisors and ward managers check day to day, for example that fire doors are not wedged open.
• Staff should follow instructions and use equipment correctly.
• Staff should report problems and danger without delay, as C155 Article 19 says.
• Staff should cooperate with the employer, for example by attending drills.
• Wedging fire doors open was a staff failure caused by weak management, so managers should offer a practical alternative such as door holders linked to the alarm.
• The HD should not have blamed the contractor alone, since the employer remains responsible for people in its care.

Marks counted: 0 of 14