Report says lessons can be learned

The seminar, staged at London’s Regent’s Park College, provided the first public airing for a revealing report on the fire at Great Ormond Street Hospital, which occurred on the morning of 29 September last year, apparently starting in a small room in the famous children’s hospital’s Cardiac Building. The detailed paper was based on witness statements, mainly from estates and facilities staff, involved both at the time of the fire, and during the subsequent investigation. Mike Ralph (now director of estates and facilities at the Mayday Healthcare NHS Trust in Croydon) stressed that, while the report (which also incorporates information provided by the forensic investigation team at Hawkins Associates engaged by the NHS Litigation Authority to investigate the incident) had primarily been written for staff and management at the Great Ormond Street Hospital for Children NHS Trust, he hoped the findings might also prompt other healthcare organisations to review their own arrangements to improve fire safety on their estate.

Incident timeline

 Based on the data recorded by the Trust itself (timings are as per those indicated on the Trust’s own equipment, although some discrepancies were found between the timings recorded by the CCTV system and the fire alarm system due to them not being synchronised ), the timeline of major events on the day was as follows:
 6.30:00 (based on witness data) – A nurse enters a four-bedded bay being used as day room in the Ladybird Ward located on the fifth floor of the hospital’s Cardiac Building, to discover that a television set there is on full volume, despite the room being empty and the lights being off. The nurse is unable to reach the main socket on the wall above the television, so turns down the volume, but the set is left on.
8.30:00 (witness data) – A cleaner goes into the day room to empty a refuse bin and notices a smell of “burning plastic”. She remembers afterwards that the television was still switched on.
8.30:50 – A “Fire Alarm Reset” is recorded in the system in the corridor of the hospital’s Southwood Building – this was subsequently identified as a routine part of the weekly schedule test programme for the site.
8.31:33 (fire alarm data) – A “fault” message flashes up on the East Link Corridor of the Southwood Building, but this is attributed to the system reset that had occurred shortly before.
8.33:05 (fire alarm data) – The fire alarm “K5008 4-bed war cardiac ionisation detector” is the first to activate. Two of the Trust’s fire & security team go to investigate, since no test was planned for the Cardiac Building that day. (witness data) – After the fire alarm activated the cleaner returned to the dayroom, saw heavy smoke, and ran out to call for assistance. A senior nurse then entered the room, saw flames around the set, immediately went out, and began evacuating patients from the ward. (fire alarm data) – Shortly afterwards fire alarm K5008 “reset”.
8.30:40 (CCTV footage) – The Trust’s fire & security team arrive in the corridor leading into the area outside the Ladybird and Badger wards, confirm by radio that a fire is in progress, and request that the fire brigade be advised.
8.31:10 (CCTV footage) – The fire & security team return in the direction of K5088.
8.35:00 (London Fire Brigade record) – The hospital’s switchboard calls the LFB.
8.35:14 (CCTV) – People are seen to be evacuating from the direction of the Ladybird and Badger wards.
8.36:34 (fire alarm data) – Fire alarm “K5097 optical smoke detector alarm” in the corridor outside the day room activates 3.5 minutes after the first activation.
8.37:03 – Fire alarm “Cardiac Level 8 plant room optical smoke detector” in plant room adjacent to K5088 activates.
8.37:25 (CCTV) – Evacuation of patients continues. Around a minute earlier “numerous” fire & security and works department staff are seen to be in attendance.
8.38:47 (CCTV) – London Fire Brigade arrives and firefighters pick up fire extinguishers from the level 5 Link Area. A member of the works department later confirms that the LFB asked him to fetch additional extinguishers from adjacent areas, which he did.
8.39:49 (CCTV) – A female gets the hose reel from the Level 5 Link area and pulls it out in the direction of K5088.
8.39:54 (CCTV) – The hose reel is passed to the firefighters, who attempt to use it to extinguish the blaze, but this does not prove effective.
8.42:33 (fire alarm data) – “Fire alarm K5086 patient room smoke detector”, located in the room immediately adjacent to the incident room, activates (around nine minutes after the first activation) (witness data) – Shortly afterwards the firefighters leave the area to connect a 45mm jet to the main fire riser and, as they walk out of the room, an explosion occurs. One firefighter is injured and is attended by a doctor. A fire & security team member radios for an ambulance.
8.44:39 (fire alarm data) – “Fire alarm K5094 exam room ionisation smoke detector” in room opposite K5088 activates.
8.45:00 – Fire alarm “K5084 optical smoke detector” at nurses’ station activates.
8.47:00 – The area is secured.