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CASE STUDY This case study provides a detailed study of five London hospital fire incidents and one on AMRI hospital Kolkata. Each scenario provides a unique perspective from six different events and healthcare settings. These comprise a substantial fire at a leading cancer hospital, a large inner London teaching acute hospital, a major childrens hospital, a medium secure mental health facility and a large outer London acute hospital. The case study highlights issues relating to substantial evacuation of hospitals and how they may be overcome using fire risk assessment methodology. 3.1 ROYAL MARSDEN HOSPITAL FIRE 1) Fire hazards Sources of ignition Sources of fuel Faulty or misused electrical equipment Arson, e.g. by patients who suffer from mental illness.

Wall and ceiling hangings and linings Plastics and rubber materials Surgical items Polyurethane foam-filled furniture, foam-filled mats and polystyrenebased display materials Sources of air around and ventilation system oxygen medical oxygen 2) People 78 inpatients and approximately 120 outpatients at Risk 3 patients were in the operating theatres and six patients were in ICU 3) Evaluate the risk As the Fire started from the top floor. There was a risk of Evaluate, falling roof. and act Act to reduce Complete evacuation of a hospital in 28 minutes due to the risk fantastic staff teamwork, good communication, leadership and Excellent pre-planning 4) Record It was recorded that revolving doors at the entrance and exit Record, to the hospital do not accommodate the width of the mattress plan and on which some patients were placed train The interruption of electricity to the burning building and adjacent perimeter areas resulted in the loss of the lights to the car park, where most of the response team were situated. In the middle of the night staff had to pick their way in the dark through fire hoses and debris. no contingency plans in place for the provision of additional staff It was recorded that possibility of a complete site evacuation was never thought. It had always been assumed that the building would be compartmentalised and a horizontal evacuation would suffice

 During the fire internal control room of the hospital was destroyed, hence major communication took place through mobile phones because of which many problem were faced Hospital staff faced too many problems in finding out side sheltering areas. Faced problem to continue medical care for sheltered patients Plan They planned to simulate patient evacuations to allow them identify and correct similar practical problems before a real incident Based on the significant finding the hospital staff were instructed and trained Revolving doors at the entrance/exit to the hospital were made wider. Incorporate the possibility of a complete site evacuation and trained the staff accordingly Two separate control rooms for future incidents, one located inside and one outside the main hospital building. Sheltering areas outside the hospital building, already identified People were trained for worst case scenarios. Staff trained so that they can continue medical care for sheltered patients. Other emergency services are made aware of potential evacuation shelter locations

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3.2 University College London Hospital fire 1) Fire hazards Sources of ignition Sources of fuel Faulty or misused electrical equipment Waste products, particularly finely divided items such as surgical items Shredded paper and wood shavings, off cuts, and dust Plastics Rubber materials Polyurethane air around and ventilation system

Sources of oxygen

2) People Women in emergency department attending in labour. at Risk 3) Evaluate the risk As the fire started in basement that to in night. It damaged Evaluate, the underground structures including IT networks, cabling, and act oxygen and air supplies tubes. Act to reduce Patients were not evacuated during this incident, outpatient the risk clinics were not cancelled and only three emergency caesarean sections were diverted to neighbouring hospitals 4) Record During the incident telephone systems in the EGA which

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had failed were replaced by mobile telephones which also provided a temporary system for crash bleeps to alert medical and nursing staff when patients are critically unwell and need rapid and urgent assessment. It has been identified that communications with the pathology labs were also disrupted, this lead to problem in contacting pathology for results In this incident the pneumatic tube system was disrupted by the fire and a replacement courier system was activated providing a continuous transport of samples between the hospital and laboratory. There was no evacuation and sheltering plan. . They planned to simulate patient evacuations to allow them identify and correct similar practical problems before a real incident Based on the significant finding the hospital staff were instructed and trained UCLH has improved their telecommunications (mixture of VoIP and analogue phones) and IT resilience (second data centre based off site). In addition UCLH are purchasing additional hand-held radios for the trust which will be ready and waiting in the event of a future major incident affecting the usual lines of communication The evacuation and sheltering plans were rewritten to incorporate both vertical and horizontal evacuation, and consider in more detail suitable areas to shelter patients if required. The protocol for the failure of the tube system was simply put into action but it took eight weeks for the system to be repaired.

3.3 Great Ormond Street Hospital fire Faulty or misused electrical equipment Medical Instrument Wall and ceiling hangings and linings Plastics and rubber materials Surgical items Polyurethane foam-filled furniture, foam-filled mats and polystyrenebased display materials Sources of air around and ventilation system oxygen Oxygen cylinder busted. 2) People 335 inpatient at Risk evacuation of 23 children with cardiac or respiratory disorders 3) Evaluate the risk As the fire started from fifth floor cardiac wing and oxygen 1) Fire hazards Sources of ignition Sources of fuel

Evaluate, and act Act to reduce the risk

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cylinder exploded in a side room, causing the ceiling to collapse. Hence all the people in Cardiac wing and nearby wing were at life risk. As a consequence of fighting the fire water soon leaked to the floors below causing the entire block, including wards, radiology, ICH labs and the admissions unit to be evacuated. Hand-held radios were used GOSH used e-mail to communicate the incident throughout the hospital. One problem identified with BlackBerries was that Microsoft Word attachments could not be opened in some cases so information could not always be extracted. Mobile telephones were most commonly used along with email. Hand-held radios were used, but staff not used to using them tended to use them like mobile telephones which became confusing. Some staff members were unaware that there was an ongoing incident. . They planned to simulate patient evacuations to allow them identify and correct similar practical problems before a real incident Prior to the incident, training had been held for key staff including tabletop simulations. This training was enhanced when ward sisters attended an evacuation training exercise at Heathrow airport Incorporate the possibility of a complete site evacuation and trained the staff accordingly Two separate control rooms for future incidents, one located inside and one outside the main hospital building. Sheltering areas outside the hospital building, already identified People were trained for worst case scenarios. Staff trained so that they can continue medical care for sheltered patients. Other emergency services are made aware of potential evacuation shelter locations

3.4 The Chase Farm Hospital fire 1) Fire hazards Sources of ignition Sources of fuel Faulty or misused electrical equipment Mentally ill patient Dust bins and waste littered on the floor Wall and ceiling hangings and linings Plastics and rubber materials Surgical items Polyurethane foam-filled furniture, foam-filled mats and polystyrenebased display materials

Sources of oxygen 2) People at Risk 3) Evaluate the risk Evaluate, and act Act to reduce the risk 4) Record Record, plan and train

air around and ventilation system medical oxygen 70 patients As the Fire started in one wing of hospital it poses threat to all the people in that wing. Horizontal evacuation and 100 fire fighters were called There were no alternative plans outlining where these patients could take shelter outside the primary building. It was recorded that possibility of a complete site evacuation was never thought. It had always been assumed that the building would be compartmentalised and a horizontal evacuation would suffice During the fire internal control room of the hospital was destroyed, hence major communication took place through mobile phones because of which many problem were faced Hospital staff faced too many problems in finding out side sheltering areas. Faced problem to continue medical care for sheltered patients They planned to simulate patient evacuations to allow them identify and correct similar practical problems before a real incident Based on the significant finding the hospital staff were instructed and trained Revolving doors at the entrance/exit to the hospital were made wider. Incorporate the possibility of a complete site evacuation and trained the staff accordingly Two separate control rooms for future incidents, one located inside and one outside the main hospital building. Sheltering areas outside the hospital building, already identified People were trained for worst case scenarios. Staff trained so that they can continue medical care for sheltered patients. Other emergency services are made aware of potential evacuation shelter locations

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3.5 Northwick Park Hospital fire 1) Fire hazards Sources of ignition Sources of fuel Faulty or misused electrical equipment Electric spark Wall and ceiling hangings and linings Plastics and rubber materials

Sources of oxygen

2) People at Risk 3) Evaluate the risk Risk of smoke filling the whole hospital Evaluate, Act to reduce Complete evacuation of a hospital in 28 minutes due to and act the risk fantastic staff teamwork, good communication, leadership and Excellent pre-planning 4) Record Communication was felt to be one of the key areas for Record, concern during the response to the fire. The first hour of plan and communications between staff, different command levels train and emergency services was described as one of the hardest. If new staffs join then he has less idea about the place. This was observed during the incident It was recorded that possibility of a complete site evacuation was never thought. It had always been assumed that the building would be compartmentalised and a horizontal evacuation would suffice During the fire internal control room of the hospital was destroyed, hence major communication took place through mobile phones because of which many problem were faced Hospital staff faced too many problems in finding out side sheltering areas. Faced problem to continue medical care for sheltered patients Plan They planned to simulate patient evacuations to allow them identify and correct similar practical problems before a real incident Based on the significant finding the hospital staff were instructed and trained Important changes were made in staff training after the incident. Fire training at Northwick Park Hospital has been completely updated. Approximately one hundred staff have subsequently been trained as fire wardens. Each department has their own departmental training, including medical staff.. Incorporate the possibility of a complete site evacuation and trained the staff accordingly There have been subsequent drives to improve staff knowledge of Northwick Parks major incident and internal incident plans. On the day of the fire the incident response was coordinated by one of the EPOs who knew the major incident plan in detail and could work closely with the Chief Executive. Subsequently the major incident action cards

Surgical items Polyurethane foam-filled furniture, foam-filled mats and polystyrenebased display materials air around and ventilation system medical oxygen 600 inpatient district

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have been updated to include more detail allowing somebody with less experience to manage a similar incident, at least in the initial stages. Sheltering areas outside the hospital building, already identified People were trained for worst case scenarios. Staff trained so that they can continue medical care for sheltered patients. Other emergency services are made aware of potential evacuation shelter locations 3.6 AMRI hospital Kolkata 1) Fire hazards Sources of ignition Sources of fuel highly inflammable medial material Waste products, particularly finely divided items such as surgical items Shredded paper and wood shavings, off cuts, and dust Plastics Rubber materials Polyurethane air around and ventilation system medical oxygen 164 in-patients

Sources of oxygen

2) People at Risk 3) Evaluate the risk As the Fire started from basement and the hospital have Evaluate, centralizes air-condition so no ventilation was there so it lead and act to smoke getting entrapped inside the building. This lead to suffocation and death of 89 people. Act to reduce the risk Record As per the reports no significant majors were taken by the authority. Fire fighters were called after 2 hour. Most of the victims choked to death on the upper floors Hospital authority took long time to decide whether to evacuate or not. No ventilation channel for the smoke to come out. The basement where the fire started housed a pharmacy, a central storeroom and the biomedical department, all containing inflammable articles The hospital authorities did not inform the Fire Department about the incident. It was the local police station that made the call. The hospital staff were nowhere in sight. All doctors had switched off their phones. And, shockingly, the guards allegedly locked the gates and vanished Hospital staff faced too many problems in finding out side sheltering areas.

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Entrance to the hospital was very narrow Must provide a ventilation system to the outside in case of emergency Incorporate the possibility of a complete site evacuation and trained the staff accordingly to react in emergency situation Hospital authority should be trained to how to cooperate Entrance should be made wider. Sheltering areas outside the hospital building, already identified People were trained for worst case scenarios. Staff trained so that they can continue medical care for sheltered patients. Other emergency services are made aware of potential evacuation shelter locations