Fire! Fire! I’m a patient, get me out of here!

Fire! Fire! I’m a patient, get me out of here!

09/06/2014

Now that I’ve got your attention, I have an important question to ask: “In the event of a fire, can you get all persons out of your ward/department to a place of relative safety without the assistance of external agencies?”

Fire safety in the field of healthcare is challenging given that at least some patients will require a degree of assistance from healthcare staff to ensure their safety. The recent fire in a mental health ward at a Hospital illustrates that the risk of fire remains very real.

The following article explores the latest guidance and provides a practical guide to protecting your organisation and staff from the risk of potential prosecution in the event of an injury sustained in a fire.

What are your Responsibilities?

In general, NHS staff have a duty of care to protect the public, and a responsibility under health and safety legislation to maintain a safe environment for patients, visitors and staff.

These pieces of legislation are particularly important:

  1. Health & Safety at Work etc Act 1974: Confers a duty upon employers to conduct their undertaking in such a way to ensure, so far as is ‘reasonably practicable’ that their employees and other persons are not exposed to risks to their health and safety, and employers should provide the requisite information required. There is a duty upon Trusts to take such measures as it is reasonable to take to ensure, so far as is ‘reasonably practicable’, that the premises, all means of access thereto or egress there from available for use by persons using the premises, and any plant or substance in the premises or, as the case may be, provided for use there, is or are safe and without risks to health.
  2. The Management of Health and Safety at Work Regulations 1992:
    Employers are required to undertake assessments of all risks to which employees and others who may be affected by their work activities may be exposed. Regulation 7 deals with procedures for serious and imminent danger and requires that every employer must: (a) establish procedures to follow in the event of serious and imminent danger to persons at work, including risks from non-occupational sources, such as fire; and (b) nominate competent persons to implement the above as regards evacuation of premises.’
  3. Building Regulations 2010: These primarily relate to the design and construction of the building in considering fire precautions.
  4. Regulatory Reform (Fire Safety) Order 2005: Requires the Trust board to put in place all necessary fire precautions to protect relevant persons in the event of a fire. This means that the person in charge of a ward at any given time will be subject to the same responsibilities as the Responsible Person, to the extent of the elements they control. All employees must also take reasonable care of themselves and others who may be affected by their work. This necessitates that a suitable and sufficient assessment of risk is undertaken.
  5. The Disability Discrimination Act 1995 and Equality Act 2010: It is unlawful to treat someone in a way which directly or indirectly discriminates against an individual on the grounds of their disability. Employers have a duty to take 'reasonably practicable' measures to protect workers, and those affected by their work activities, from the risk of injury or harm at work.
  6. The Human Rights Act 1998: Staff have a positive obligation to preserve life and use no more force than is absolutely necessary.

The Health Technical Memorandum 05-01: Managing Healthcare Fire Safety (April 2013) provides guidance which is intended to complement the current legislation regarding fire safety but specifically looks at fire safety within the healthcare setting. Due to the characteristics of patients on wards, the Guidance recognises that the appropriate fire safety management level is Level 1, which requires that a number of steps should be taken, including ensuring that the staffing level is appropriate and sufficient staff are trained in all aspects of fire prevention, protection and evacuation procedures. Contingency planning needs to be proactive.

The organisation must be able to demonstrate that the fire emergency action plans in place are appropriate and sufficiently robust so as not to rely on other agencies for evacuation. The BS 9999:2008 guidance confirms that 'stay put' fire evacuation plans for disabled people which may involve awaiting assistance from the Fire and Rescue Service, are no longer defensible. Section 46.1 of the Guidance states:

'It is important to note that it is the responsibility of the premises management to ensure that all [emphasis added] people can make a safe evacuation. The evacuation plan should not rely on the assistance of the fire and rescue services.'

The earlier Health Technical Memorandum 05-02 guidance acknowledges the challenges that may occur in evacuating mental health patients and states that 'management and operational policy should ensure that the patients are adequately separated from the fire while they are being transferred to a secure area.' Whilst this is acknowledged, no practical guidance is provided for trying to assist with the evacuation, and address the difficulties that may be encountered.

Personal Emergency Evacuation Plans (PEEPs)

PEEPs are a means by which arrangements are made to ensure that an individual's physical or mental abilities or other circumstances do not prevent individuals from responding to an alarm and leaving the building or moving to a designated place of safety.

The Regulatory Reform (Fire Safety) Order 2005 (FSO) requires employers or organisations providing services to the public to take responsibility for all people, including disabled people, to evacuate buildings safely. The FSO replaced the requirement for fire certificates and in so doing moved the fire safety emphasis on to prevention by using a risk-based assessment method. Whilst the FSO is intended to protect employees, it must take account of any duty of care the Trust has to other occupants of the building, in this circumstance, patients. The capabilities of all persons using the building must be considered.

What steps should you take?

A ‘stay put’ evacuation plan whilst you await the arrival of the Fire and Rescue Service is no longer acceptable. There should instead be a risk assessment which includes a clear emergency evacuation plan and how it will be implemented.
Within all settings, but with a higher prevalence within the mental health setting, there may be a risk of violence towards staff which may increase during a fire evacuation as anxieties increase. Decreased mobility and very unwell patients are a challenge within the acute setting.

The following steps should be taken, incorporating the potential for violence:

  1. Identification of evacuation barriers across the property portfolio;
  2. Early identification of risk – consideration should be given the building design and physical environment. Patients should be appropriately placed on admission taking into account risks, such as, reduced mobility or likely violence in the event of a fire;
  3. Complete an assessment of risk for the group of patients in the event of a fire incorporating potential scenarios, such as a violent patient who refuses to leave – complete PEEPs;
  4. Assignment of roles and responsibilities – who does what and when (vulnerable individuals may wander and a carer may need to comfort a distressed person before evacuation whilst patients with decreased mobility will require assistance);
  5. All staff must be aware of the fire evacuation procedures, plans, exit points, how to use fire extinguishers and how to get help;
  6. Implement PEEPs within existing processes in a non-discriminatory manner;
  7. Monitoring and review of PEEPs processes regularly, to include consultation with the individual and their families. All efforts should be made to help the patient fully understand the evacuation process (consider the means by which evacuation plans should be best communicated, use of photographs/illustrations, simple English, buddies etc);
  8. A rehearsal of the evacuation plan and PEEPs should take place periodically and be sufficiently rehearsed.
  9. Staff must have received appropriate training regarding fire evacuation, but also in Positive Behaviour Management and Prevention and Management of Violence and Aggression to forcibly remove the patient from the building if absolutely necessary, i.e. de-escalation techniques are unsuccessful, or the increasing ferocity of the fire necessitates immediate action. This scenario should have been risk assessed and planned for in advance, and all staff should have a clear understanding of the fire evacuation plan/s.
  10. Remove a patient from the building if necessary;
  11. There should be sufficient staff on duty so that if a patient requires assistance by a carer to evacuate, one is available. There should also be sufficient staff working who have the requisite training outlined above.
  12. Discuss all plans with your local Fire and Rescue Service to take into account their experience and agree a protocol for tackling fires as you will be working in partnership.
  13. Review the organisation’s internal policies to ensure that the plans which follow in the event that a fire occurs, are compliant with the Trust's own internal policies, as well as key legislation and guidance, as set out above.

Summary

Now is a good time to review your fire evacuation procedures and policies to ensure they are up to date with current legislation and guidance. Should a fire occur which results in the death of a service user, a number of agencies may investigate the matter and could consider prosecution of an individual member of staff, a Director or of the organisation as a whole. There is some overlap between possible offences/claims but the prosecutions may result in a fine, or in some circumstances possible imprisonment. There is also the potential for disciplinary hearings, attendance at an inquest and the resulting adverse publicity.

Whilst the enforcing agencies may have a degree of sympathy to the challenges that staff are likely to face in ensuring that a building is safely evacuated in the event of a fire, it is essential that you are able to demonstrate that forward planning took place, identifying the risks and the steps that were taken to ensure the safety of persons on the ward. The key to avoiding the possibility of potential prosecution is in the planning stages. The 'Responsible Person' must carry out, and keep up to date, a suitable and sufficient risk assessment and implement appropriate measures to minimise the risk to life from fire. This should identify any potential risks arising from the workplace, including aggressive service users who may refuse to evacuate the building, and should assess the likelihood of harm and the potential severity of the harm if it occurred. The risk assessment should be monitored and reviewed and reflect any changes in a patient’s presentation/condition which may require changes to the fire evacuation planning.

There will be no way of avoiding a potential prosecution if all reasonable and practicable steps have not been taken in advance to try and ensure the safety of vulnerable patients. In being able to prove this, documentation is key and there should be a clear audit trail. The organisation should be able to demonstrate that there are robust systems in place for dealing with fire evacuation. The HSE, CQC and the police will all request documentation to consider whether suitable steps were taken. During a fire itself, staff will be expected to act in accordance with the duty of care they owe to all patients. The Responsible Person will need to exercise judgement as to the most appropriate response during a fire, but this should be dictated by the risk assessments and plans already in place.

Finally, liaise with your local Fire and Rescue Service to agree a local protocol. If you still have concerns, speak to your local Health and Safety Executive Inspector, and Care Quality Commission lead, to seek their input into making your risk assessments as robust and effective as possible. 

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