COLDHARDOUR HOSPITAL (FIRE) (Hansard, 13 December 1972)

§ The Secretary of State for Social Services (Sir Keith Joseph)
With your permission, Mr. Speaker, and that of the House, I should like to make a statement on the Report of the Committee of Inquiry into the fire at Coldharbour Hospital, Sherborne, Dorset, on 5th July 1972, when 30 mentally handicapped patients so tragically lost their lives. I should like to pay tribute to the Committee under the Chairmanship of Mr. Desmond Vowden, QC, for the thorough and expeditious manner in which they carried out the inquiry. The report is being published today as Cmnd. Paper 5170. Copies are available in the Vote Office.
Publication of the report had to be deferred because, in view of certain of its findings, I thought it right to refer the papers to the Director of Public Prosecutions. The Director has now decided that the evidence does not warrant criminal proceedings against any person.
The Committee of Inquiry finds that the night staff were absent for a much longer period than is acceptable; and that the spread of the fire was accelerated and its effect made more serious by the materials of the partitions and furnishings in the ward, the specification for which had been altered in some respects without the consequential effect on the standard of fire resistance having been fully appreciated. The Committee considers that the fire alarm arrangements were adequate and worked well; that the actions of the fire brigade, once alerted, were efficient; and praises prompt and brave action taken by the hospital staff once the fire had been discovered. The report makes various recommendations on fire precautions and other matters. Some of these apply specifically to Coldharbour Hospital; others are of more general relevance.
I accept—and so does the Chairman of the Wessex Regional Hospital Board—the findings of the Committee of Inquiry as to the causes of the fire. The Committee's general recommendations are being urgently studied, and meanwhile I have asked all hospital authorities to review their safety measures in the light of the report. My right hon. Friend the Home Secretary, who is responsible for 442 the Fire Precautions Act 1971, has agreed that, as recommended in the report, the designation of hospitals under that Act should now proceed as soon as practicable.
The report records full approval of the policy that mentally handicapped patients should live in a more domestic atmosphere, and of the principles followed at Coldharbour to achieve this. It stresses, however, that the highest standards of safety must also be provided. These two objectives are inherently in conflict but I am seeking to reconcile them as nearly as practicable. No one would wish to go back to the dismal old institutional designs and furnishings which used to be the rule in hospitals for the mentally handicapped. That environment was not only bad for the patients, particularly for the preparation of those who will return to the community; it was also bad for the morale of staff. I am, therefore, reviewing the Department's guidance to hospital authorities, taking into account research into flame-retardant materials and consulting my right hon. Friends the Secretaries of State for the Home Department and for the Environment.
The report also refers to the need for more specialised security accommodation for patients who present a risk to others, and to the danger of leaving wards with such patients unattended for more than a very short time at night. The specialised medical and nursing care required for patients who may be a risk to themselves or others may take various forms, including either separate accommodation or special supervision in accommodation shared with other patients. My Department has a working group considering what further guidance is needed in the provision of such accommodation. I have meanwhile asked all hospital authorities to review staffing levels and supervision, including night care, in wards where such patients are housed with others who are not capable of looking after themselves. I have also asked hospital authorities to consider in this review what instructions should be given to nursing staff to ensure that they are under no doubt what is expected of them in such matters as leaving wards unattended at night for more than a very few minutes.
My right hon. and learned Friend the Secretary of State for Wales has taken 443 similar action on the general recommendations in the report, in relation to those hospitals within his responsibility.
With the best will in the world, it is not possible to guarantee that such appalling accidents as that at Coldharbour will never occur again; but we are determined that the lessons learned at such cost at Coldharbour will not be forgotten.

§ Dr. Summerskill
I am sure the House will agree that it is with tragic regularity that we seem to be discussing hospital fires. As many as 33 fires have occurred in institutions for the mentally handicapped since March, 1969. Would the right hon. Gentleman bear in mind that, as I pointed out when he replied to a Private Notice Question on 5th July this year, at least four other major hospital fires occurred in 1968, 1969, 1970 and 1971? The thing that these fires had in common was that they all occurred at night and that they all occurred in geriatric or mentally ill or handicapped hospitals.
Will the right hon. Gentleman also bear in mind that the results of the inquiry bear out that there is a particular risk to these categories of patients who clearly require extra special supervision, particularly during the night? They also require additional fire precautions as they seem to be more vulnerable to fire, either because of the age of the hospitals—although that was not the case in this hospital—or for other reasons.
Will the right hon. Gentleman recall his statement on 5th July when he pointed out that the proportion of staff to patients at this hospital was well above the recommended minimum ratio? Will he reconsider what the recommended minimum ratio should be, as clearly this was not adequate? Will he consider quality of staff as well as quantity, because in this instance the staff were shown not to be on duty when they should have been? Appreciating that it is extra hard to acquire staff for this type of hospital, would the right hon. Gentleman also give consideration to the employment of auxiliaries who might in serious situations of shortage help out at night?
Finally, will the right hon. Gentleman say whether he can provide the money sooner than was expected to bring all hospitals up to the fire authority stan- 444 dards? Is he aware that £5.75 million is required and that only £2.5 million was spent in 1971–72?

§ Sir K. Joseph
Mercifully, most of the fires to which the hon. Lady refers did not lead to loss of life. We are dealing here with the elderly, psychiatric patients and the mentally handicapped, with groups of patients who are often a danger to themselves. I am very willing to look into all the points which the hon. Lady made. In this tragedy, it was not a question of numbers of nurses or of staff ratio. It was a matter of two nurses absenting themselves from their duties for far longer than was legitimate.
As regards money, it is true that £2½ million was spent last year. I have made an extra allocation of £1½ million on top of an expected repetition of £2½ million this year, so I hope that the gap between desirable fire standards and actual fire precautions will be rapidly overtaken.

§ Mr. Wingfield Digby
Will my right hon. Friend make clear that the Sherborne fire crew acted efficiently and gallantly as soon as they received their somewhat delayed call, as it appears to have been? I welcome what my right hon. Friend had to say about combustible materials and layout, which must, surely, have led to the rapid spread of the fire. Is he convinced that all steps are being taken to keep combustible materials, matches and so on, away from patients, some of whom may have a tendency towards incendiarism? Is my right hon. Friend satisfied that nothing more can be done in this respect?
Is my right hon. Friend convinced that, if there had been early detection of the fire—which obviously there was not—the evacuation of these patients could have proceeded? Finally, could he give me an assurance that drugs played no part in the apparently slow reaction of the patients to the fire?

§ Sir K. Joseph
I am glad to repeat my tribute to the Sherborne Fire Brigade. I am not sure that there was a very rapid spread of the fire. I think that the tragedy here was that nurses were, apparently, absent for so long, and a fire which would never have caught a grip had the nurses been away for only five minutes was allowed to catch a grip.
445 There is a problem regarding combustible materials, which the nurses seek to avoid by removing them from those who have tendencies to pyromania of some sort. I am convinced that the evacuation could have been carried out perfectly safely had the fire been discovered earlier. I am not aware—indeed, the report does not refer to it in any way—of any impact of drugs on the patients.

§ Mr. Mayhew
Is the right hon. Gentleman aware that there is still a great lack of furnishings and furniture which are pleasant and comfortable while at the same time unhurnable, unbreakable and untearable? Will he do more to encourage research into the development and provision of such furnishings and furniture for hospitals of this kind?

§ Sir K. Joseph
A lot of progress has been made, but there are more problems than those to which the right hon. Gentleman refers. For instance, there is the question of the opaqueness of curtains and the capacity of bedding to be laundered while still retaining fire-resistant qualities. I am concerned about the progress of research into this, and I am arranging with my right hon. Friend the Home Secretary that I shall visit the Fire Research Station early in the new year to see a large number of flame-resistant and fire-retardant materials and fabrics.

§ Mr. Robert Cooke
Did my right hon. Friend see the recent terrifying television documentary about the effects of fire even in quite new buildings, where modern materials, even if not actually being burned, produce toxic, killing fumes under heat? Also, will he give attention to the problem of furniture made of foam rubber or plastic, in particular, which may produce toxic fumes and spread fire?

§ Sir K. Joseph
I did not see that documentary film, but my hon. Friend the Under-Secretary of State for the Home Department tells me that the Home Office is following up the toxic dangers to which my hon. Friend refers.

§ Mr. Russell Johnston
The Secretary of State may know that the largest hospital for the mentally handicapped in the north of Scotland lies in my constituency. 446 I notice that he made no specific reference to the results of the inquiry being applied to Scotland, although he referred to Wales. I see the Scottish Minister responsible for these matters sitting beside the Secretary of State. May we be assured that the constructive lessons of this inquiry will be applied to Scotland? Second, may I underline what was said by the hon. Member for Bristol, West (Mr. Robert Cooke)? I saw that television film showing the toxic effects of burning plastic materials, and I assure the right hon. Gentleman that it was quite horrifying.

§ Sir K. Joseph
My hon. Friend the Under-Secretary of State for Scotland is on the bench with me and he has noted the hon. Gentleman's comments. As regards England, I am today sending a letter to all hospital authorities enclosing a copy of the report and drawing the lessons of it to their attention.

§ Mr. Arthur Lewis
Has the right hon. Gentleman considered the possibility of installing in all these hospitals strategically placed, out of the reach of patients, special fuse devices which would automatically go off when, as the result of either heat or toxic smoke, the danger point is reached, so that there would be a direct line of alarm to the fire station? Would this not help in the matter to which the hon. Member for Dorset, West (Mr. Wingfield Digby) referred, namely, the speed of coming to the fire, since such automatic devices could be directly connected to the fire station and in that way help to save lives?

§ Sir K. Joseph
Both the report and my letter to hospital authorities refer to the possibility of automatic detector systems. However, they should be necessary only where, for some reason, staff coverage cannot be as good as it should be. In this case there was the human element—two nurses were absent.

§ Dr. Stuttaford
Does my right hon. Friend recall that the Press photographs of this disaster showed that the patients were living in bunks? Were they not in overcrowded conditions, as is common in these hospitals, even modernised ones, and was this not a contributory factor not only to the start of the fire but to the death rate? Will my right hon. Friend say whether the patients who had died 447 were found in their beds, or had they tried to get out and been overcome by fumes or smoke?

§ Sir K. Joseph
Most of the patients, who had a mental age of five years, were killed by asphyxiation in their beds, which, considering the nature of this disaster, was, I suppose merciful. I do not accept my hon. Friend's comment that they were overcrowded. They were living in domestic conditions, not in vast institutional wards. They were living in relatively cosy rooms, admittedly with some in two-tier bunks, but in homely conditions. I am not sure, but I do not think that the inquiry refers to any possibility of overcrowding.

§ Dr. Summerskill
Will the Secretary of State clear up an important point? He seems to be saying that it was not a matter of staff shortage but that there was a human element. Ought we not to allow for human failings to some extent, bearing in mind that in this case the night nursing assistant, Mr. Rawles, was absent from the dormitory for much longer than was acceptable? Should there not be provision for such an eventuality? If a ward of patients with a mental age of five years had adequate 448 staff, could not that eventuality have been covered by other staff coming in?

§ Sir K. Joseph
The nurse had earlier been relieved for his meal by another nurse. Later he left the ward again and his charge nurse absented himself with him. When two human elements fail, I think that it is, perhaps, not reasonable to expect a third human reserve. I am well aware of the strain on nurses in these hospitals, but I am emphasising to all hospital authorities that the duty of nurses at work at night is not to leave wards of this sort for more than a very few minutes at a time, and it should be possible to rely on their charge nurses to see that this is so.