The 2006 Moscow Fire and the 1968 Shelton Hospital Fire - Case Study Example

Case studies: The 2006 Moscow fire and the 1968 Shelton Hospital Fire’ Student Institute Affiliation Course Date ‘Case studies: The 2006 Moscow fire and the 1968 Shelton Hospital Fire’. The 2006 Moscow Hospital Fire. In December 2006 on the 9th day of the month, there was a fire at a Moscow Hospital. It was a drug addict rehabilitation centre in Southern Moscow in Russia. The fire transpired on the second floor of that hospital. It was at No. 17 in a five storey building. The number of people who perished in that fire was forty five. Several days after the tragedy, one more person yielded to the injuries increasing the death toll to forty six. The people who were in the hospital had been trapped by a locked gate. Shortly after the incident, the disaster was placed under investigations but the initial conclusion was that it was arson that resulted in that fire (USA Today 2006). The tragic event. The fire that occurred pre-dawn begun in a kitchen that was situate at the end of a corridor of the same building. The wooden cabinets in that kitchen caught fire. As a result, the women’s ward of the hospital that was located in the second floor of that building quickly and massively filled up with smoke. All persons who were in the wars were thus trapped due to the fact that the main emergency exit was barred by a locked entrance and thus the only other available exit had been rendered unusable by a cloud of thick smoke. All the windows at the hospital had been shut and they were also locked. It is the belief that staff at the hospital possessed the keys that were needed to open those windows, but as it turned out later, they lacked the time to open it. an emergency call was made to the department of fire, but at the time the fire fighters arrived at the scene, all the 45 women who had been trapped in the ward including two hospital staff were already dead. It is estimated that a total of 160 people managed to be evacuated from the building out of which ten were hospitalized for poisoning as a result of carbon monoxide. Two days later, one person succumbed to the burns and passed on, it is said that that fire was the worst fire in the history of Moscow since the 1977 Rossiya Hotel fire the exact death toll still remain undisclosed and unknown (Associated Press 2006). The Russian Chief Fire Inspector one Yuri Nenashev commenting on the incident sated that he was 90 percent certain that the fire was a deliberate act. The Mayor one, Yuri Luzhkov also commenting on the same stated that the fire appeared to be a case of arson or a case of extreme careless handling of materials that are flammable (Iklim 2006). Shelton Hospital Fire. On the night of 25th to 26th February the year 1968, there was a fire at the Shelton Hospital in Shrewsbury. A preliminary report from the Regional Hospital Board of Birmingham indicated that the fire had begun around midnight on the first floor of a two storey building which was at that time accommodating some psychiatric patients who were women. It was started that the cause of the fire, as is so often the case was a cigarette end which was assumed to have arrived at the hospital (Great Britain 1968). At the time of the fire, about forty two women were fast asleep on that floor. Majority of them were elderly and some were bed ridden. According to the preliminary reports, twenty one patients died that day and fourteen other members were rushed to Royal Salop infirmary for treatment. Out of the fourteen, one was critically ill, another seriously ill and twelve were suffering from minor burns as well as shock and were thus placed under observation. The ground floor had not been damaged by the fire and there were fifty six patients sleeping there who were not harmed by the tragic fire (BBC 1968). Similarities of the two catastrophes. The absolute similarity of the two tragic events was the fact that they were both fire related incidents. Another obvious similarity is the fact that the two fires took place at hospital premises and both hospitals were accommodating only women at the exact place where the fire caused deaths. Another preliminary similarity was the fact that both fires resulted in the death of patients at the hospital. The two fires took place in the dead of the night at a time when the patients were fast asleep. Both catastrophes do not have a definite time when the fire begun. Differences of the two catastrophes. The first difference is in the location as well as in the treatment offered in the hospitals. In the Moscow tragedy, the hospital was a drug addict rehabilitation centre that was located in Southern Moscow in Russia. The other tragedy took place at the Shelton Mental Hospital which is near Shrewsbury located in Shropshire. Another difference relates to the date, time and the number of deaths that occurred. The Moscow tragedy took place on the 9th day of December 2006 past the midnight hour, the time is not very certain, however, it was noted that an emergency call was made at around 1.30 A.M. The number of deaths that took place that night was placed at forty five women and two days later one more person succumbed to burns and injuries raising the number to forty six (Associated Press 2006). The Shelton Hospital fire tragedy on the other hand, took place on the night of 25th to 26th February 1968. The fire is reported to have begun around midnight. The number of deaths that took place that night was twenty one but the final death toll was twenty four (BBC 1968). Another key difference is in regard to the exact area where the tragedy took place. In the Moscow tragedy, the fire begun in a kitchen that was on the second floor of the hospital building. The building was a five storey building. The fire caused the women’s ward that was also on the second floor to fill up with smoke. The Shelton tragedy commenced on the first floor of the hospital building. It was the floor that accommodated some psychiatric women patients. The building was a two storey building. The root of the tragic fires in the two accidents is also another key difference. The Moscow tragedy was viewed as an act of arson. The fire begun in a kitchen that was on the second floor of that hospital building. The wooden cabinets in the kitchen caught fire and as a result caused massive smoke to fill up the second floor where the women’s ward was located. The reports indicated that the patients died as they struggled to leave the building as the smoke that had filled up the place suffocated them. The doors as well as the fire escapes and exit points were apparently and allegedly locked. The windows had metal bars which could not be opened. All the victims who perished that dreadful night were women. Most of the patients were undergoing treatments for addiction of alcohol and drugs. Two of the victims were clinic staff (CBC News/world 2006). The cause of the fire at the Shelton Hospital is said to be a cigarette end which is believed was dropped by one of the patients at the hospital. The hospital ward in this case was full of severely mental disabled women who were routinely locked in the ward during the night. Most of the women were asleep at the point in time the fire was raging and some were not able to move from their beds by themselves as they needed some assistance. Most of the reported deaths are said to have been caused by smoke inhalation. The Moscow tragedy was made up of women who were recovering addicts, some were young females whereas, in the Shelton tragedy, the women were elderly and as a result some of them were unable to move without help. Fire investigations. The Moscow tragedy. The Moscow tragedy investigations as to the exact cause of the fire is hard to come through, there is mention of a formal investigation report as to the fire incident. The information that is available on the internet and in the local and international newspapers relates to the preliminary investigations and observations that were conducted shortly after the incident was reported. For instance, the Russian Chief Fire Inspector one Yuri Nenashev stated that he was 90 percent sure that the fire was a result of arson (Associated Press 2006). The tragedy was also termed by the Mayor of Moscow as an unpleasant and a very serious tragedy. The office of the city prosecutor headed by Yuri Syomin opened a criminal inquiry into the cause of the fire. The inquiry was for the ‘intentional destruction’ as well as the ‘violation of fire safety rules’. He stated that the investigations that were conducted had drawn no conclusions as to the cause of the fire (CBC News/world 2006). The preliminary investigations. Members of the fire crew at the scene who were interviewed by the Russian televisions stated that many victims were not able to escape because of metal bars that were on the windows. Other victims had been overcome by fumes while they were asleep. One of the fireman said that an emergency exit had been boarded up and the main exit had been swathed in smoke. For this reason, many victims thus succumbed to the noxious fumes from a plastic coating which had covered the walls of the hospital wars (Associated Press 2006). Investigators who had arrived at the scene and the emergency fire control department of the Ministry. The chief Yury Nenashev was of the opinion that arson was the likeliest cause for the fire that night. Klimkin said that in March the inspectors had appealed to a court for the building to be closed down due to violations of fire safety rules. The court only issued a warning to the administrators of the hospital (CBC News/world 2006). The Shelton Hospital tragedy. The Shelton tragedy was a big blow to the City and for this reason; the matter was discussed before the UK Parliament. The Minister of Health one Mr. Kenneth Robinson tabled before Parliament a preliminary report from the Birmingham Regional Hospital Board. The report indicated the time, place and victims of the fire. In view of the same, the Minister appointed a Committee of Inquiry to conduct an inquiry into the fire at Shelton Hospital, Shrewsbury. The Committee of Inquiry was composed of four members. They were: H. W. Sabin Esq., Barrister-at-Law. Mrs. E. Y. Atkinson, S.R.N., R.M.N., Matron, Stanley Royd Hospital, Wakefield. K. C. Bailey Esq., M.A., M.D., D.P.NI., Physician Superintendent, Tone Vale Hospital, Taunton. P. S. Wilson-Dickson Esq., M.B.E., H.M. Inspector of Fire Services, Home Office (HANSARD 1968). The Committee was appointed in the same year. The terms of reference of the Committee of Inquiry were to conduct an inquiry in compliance with the provisions of the National Health Service Act of 1946 at Section 70. They were to inquire into the circumstances that lead to a fire at the Shelton Hospital. The Committee was then to make a report and present to the Minister of Health (HANSARD 1968). The committee findings: The evidence before the Committee revealed that the hospital which was built in the mid-nineteenth century was sound as far as the structure was concerned. In some respects, the building was thought to be much safer than some modern buildings. The central heating system as well as the electrical system was modern. The numbers of hydrants at the hospital were sufficient and there was a full provision of hose reels. The equipment of fire fighting appeared to be in first class condition. There was a conventional ‘break-glass’ fire alarm system which had been well maintained and which was adequate within its limits (Great Britain 1968). The telephones at the hospital existed, both the internal and G.P.O and were thus capable of being used to raise an alarm. The Committee in regards to the telephones stated that a high level of proficiency was needed in order to utilize the various media means if delay and confusion were to be avoided. The Committee was of the view that all the necessary paraphernalia for raising an alarm and fighting fire were in available and were in good order (Great Britain 1968). The report thus found that the faults that existed which are and where the grievous ones, were human. The staff had had no training whatsoever in fire safety and procedure (Great Britain 1968). Human factors that led to loss of life. At the Moscow tragedy. The fire department spokesman Mr Yevgeny Bobylyov said that the earliest call to the fire department was at around 1:30 Am and this was made very late considering the gravity. He said that the hospital administration was at fault because they did not work in a fashion and way that was prudent and proper in a fire situation. He also said that the fire services were informed thirty minutes too late. In addition, he stated that the staff failed to use their keys to open the grilles for purposes of evacuation and because of this people were caught in a trap (BBC News, 2006). He also stated that the hospital personnel did not work well as they failed to take steps to evacuate the people during the early stages of the fire. The Deputy Emergencies minister Alexander Chupriyanov also remarked that all the people were dead before the fire engines arrived at the scene. He added that the fire crew had responded to the emergency call in just four minutes and evacuated the hospital which at the occasion of the fire had a total of fifteen staff and one hundred and seventy seven patients. It cannot go without say that there were also suggestions that indicated that the staff had been rapidly overcome with the smoke and for this reason they had been incapable of taking action in the circumstance. Yuri Nenashev, the chief fire inspector of Russia said that said fire inspectors had on two occasions visited the hospital in February and March, and had made their recommendations about safety concerns. They made recommendation regarding the hospital and, during their second visit they suggested that the facility be closed temporarily (Associated Press 2006). At the Shelton Hospital. During the fateful day, there were only two nurses on night duty who were being assisted by an unqualified junior. Together they were responsible for ninety eight of the hospital’s most severely patients who were mentally ill. The night nurse who was in sole charge of the ward to which the fire was confined was summoned by the Committee and critiqued for her failure to give timely warning of the fire. The nurse’s degree of culpability was reduced when it was revealed that she had never received any training in procedure of fire in the whole of her twenty two years of health service (Great Britain 1968). Nevertheless the staff at the hospital did their level best in the difficult situation. The death toll nonetheless was a reflection of the fact that no night staff had been trained as to the manner in which to evacuate the premises in the case of a fire. Tragically, it was found that there had been a delay between the time when the smoke was first noticed and when the alarm was raised. The delay was about ten minutes which according to the Shropshire Fire service were vital and the results might have been far much less tragic (Information Britain. 2009). Similar and different human factors. In both tragedies, the hospital staff contributed to the large loss of life. For instance, in both tragedies it was reported that there was a delay in making of emergency calls. In the Moscow tragedy the delay was for thirty minutes whereas at the Shelton tragedy, it was stated that the delay was for ten minutes. The Moscow tragedy was a disaster in the waiting because earlier in that year, inspectors had visited the hospital and recommended closure of the facility due to violations of safety. In the Shelton tragedy, evidence availed to the committee revealed that the hospital was in good conditions structurally and as far as the response to emergency was concerned. The only disadvantage is the fact that the staff lacked formal training in fire response situations. In regards to the Moscow tragedy, the fire department spokesman Mr. Yevgeny Bobylyov said that the hospital personnel did not work well as they failed to take steps to evacuate the people during the early stages of the fire (USA Today 2006). The Shelton Hospital staff was commended because they did their level best in the difficult situation. The efficiency of the staff at the hospital was as a result of lack of training in hospital evacuation response. Lessons learnt. The principle lessons to be learned from the tragedies are first and foremost, that fire-fighting is job exclusively for professionals and thus the sooner they are summoned the greater the chances for saving lives. Closely related to this is communication. Communication between any area or part of a hospital, the hospital centre for fire control and the local fire service should be ideally be simple, clear and foolproof as is humanly possible (Leading Articles. 1969). Ideally, rising of a fire alarm ought to be able to register directly at the headquarters of the fire service. There should be a chain of command and training of all grades of staff at the hospital in emergency fire response and evacuation procedure. The training ought to be in the form of demonstrations, lectures, use of dummies and frequent fire drills by officers at the fire department (Great Britain 1968). There was in no doubt an assumption as regards the state of the patients at the two hospitals. For instance, the Shelton Hospital was a mental hospital and thus most of the victims were helpless in mind and body. At the Moscow tragedy, the hospital accommodated recovering addicts some of who obviously were not mentally stable. This should feature as a concern when designing and implementing procedures in cases of fire emergencies. As stated, the later accident was one that was in waiting. The hospital was in total regard to safety as they were in violation of the same. For instance, the windows in the five storey building had been barred and the fire safety concerns that had been raised had been ignored. The first incident did serve as a lesson to the entire world on the benefits of training hospital staff to handle fire emergency situations. Despite and efficient system, if the staff fails to rapidly report to the fire department, death will still occur in cases of fire emergencies. The Russian government has been slow and reluctant to open its institutions to inspectors from health and safety, monitors of human rights and inspectors from fire departments. The government is also unwilling to follow the recommendations brought by those bodies. Actually, the Country has experienced worse incidents that this one, but there have been no improvements. As a result, there is likely to be a reoccurrence of the incident maybe in other premises. It is unlikely that the tragedy at the Shelton Hospital will reoccur; this is due to the investigations and recommendations that were adopted following the incident. For instance, after the fire at Shelton, fire safety procedures at the hospitals in Midlands were revised and reviewed (Leading Articles 1969). References. Associated Press. (2006). Tight security blamed for deaths in Moscow fire. Retrieved March 16, 2012 from http://www.msnbc.msn.com/id/16116136/ns/world_news-europe/t/tight-security-blamed-deaths-moscow-fire/#.T2QWqHryGSq BBC NEWS. (2006). Moscow drug clinic kills 45. Retrieved March 16, 2012 from http://news.bbc.co.uk/2/hi/6163835.stm BBC. (1968). 1968: Hospital blaze kills 21 patients. Retrieved March 17, 2012 from http://news.bbc.co.uk/onthisday/hi/dates/stories/february/26/newsid_2758000/2758419.stm CBC News/world. (2006). Arson suspected in deadly Moscow Hospital fire. Retrieved March 16, 2012 from http://www.cbc.ca/news/world/story/2006/12/09/moscow-fire.html Great Britain. Committee of Inquiry into the Circumstances leading to a fire at Shelton Hospital, Howard Sabine (Chairman.) (1968). Report of a Committee of Inquiry into the circumstances leading to a fire at Shelton Hospital on the night of 25th to 26th February 1968, and to the deaths of 24 patients. United Kingdom: Ministry of Health. HANSARD. (HC Deb 10 April 1968 vol 762 c280W). (1968). Shelton Hospital Fire (Inquiry). Retrieved March 17, 2012 from http://hansard.millbanksystems.com/written_answers/1968/apr/10/shelton-hospital-fire-inquiry Iklim. (2006). 42 killed in Moscow hospital fire. Retrieved March 16, 2012 from http://www.iklimnet.com/hotelfires/hs_case18.html Information Britain. (2009). Shelton Hospital Fire. Retrieved March 16, 2012 from http://www.information-britain.co.uk/famdates.php?id=662 Leading Articles. (1969). ‘Hospital Disaster’ British Medical Journal, pp 66-67. Retrieved March 17, 2012 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1982033/pdf/brmedj02014-0022.pdf USA Today. (2006). Fire in Moscow hospital kills 45 people. Retrieved March 16, 2012 from http://www.usatoday.com/news/world/2006-12-08-moscow-hospital-fire_x.htm Read More