A fire broke out in the early morning hours of November 18, 2011 at a residential aged care facility in Sydney, Australia. At least 11 residents died as a direct result of the fire and nearly 100 were evacuated. A nurse was been charged with 11 counts of murder as the fire is believed to be a result of arson. The nurse pleaded guilty to all 11 counts on May 27, 2013. (There have been other resident deaths but due to their age and health, it wasn’t clear if the deaths were a direct result of the fire.)
The cause of the fire initiation resulting in the deaths of residents, evacuation and severe damage to the nursing home facility is believed to have been arson. The reasons for the arson are unclear and may never be fully understood. However, there is still value in analyzing the event to determine if there are any other solutions that could reduce the risk of patient death in the future, at this facility or at others.
We can perform a root cause analysis in the highly visual, intuitive form of Cause Mapping to understand the issues that led to the tragedy. We begin the analysis with the “What, When and Where” of the event, captured in a problem outline. Additionally, we capture the impacts to an organization’s goals. In this case, the patient safety goal was impacted due to the deaths. There was an impact to employees, as a nurse at the facility has pleaded guiltily to murder. Patient services were impacted due to the evacuation of the nearly 100 residents at the facility. The severe damage to the site resulted in the construction of a new facility, which cost $25 million. (The cost of the new facility cannot all be attributed to the fire, as the new facility is much larger and has been modernized.) Last but not least, the labor goal was impacted due to the incredibly heroic rescue efforts by the staff, firefighters and other rescue personnel, who were honored for their efforts.
Capturing the frequency of similar issues can help provide perspective on the magnitude of nation and world-wide issues. I was unable to find data on the prevalence of nursing home fires in Australia, but there are more than 2,000 nursing home structure fires in the United States every year. There have been a number of fatal nursing home fires in Australia over the last several years, so this is obviously a concern for the nation.
Once we have determined the impacts to the goals, we can ask “Why” questions to determine the causes that resulted in those impacts. In this case, the resident deaths were due to smoke inhalation and complications from smoke inhalation as the result of a fire that spread through the facility. The fire initiation, as discussed above, is believed to be due to arson. However, it is believed that staffing levels and lack of an automatic sprinkler system were related to the spread of the fire, speed of the evacuation and the number of deaths.
Studies after the event showed how critical sprinklers can be to slow the spread of a fire. On January 1, 2013, the government of New South Wales passed a law requiring installation of automatic sprinkler systems in all residential aged care facilities prior to January 1, 2016. It is hoped that the presence of an automated sprinkler would slow or prevent the spread of a fire, resulting in fewer resident deaths.
To view the root cause analysis investigation of the fatal fire, please click “Download PDF” above.