Lessons from the Quakers Hill Nursing Home fire

For owners and operators of aged care facilities and other high dependency accommodation

The Quakers Hill nursing home fire was the most complex and intensive fire rescue operations undertaken by FRNSW in many years. The actions of firefighters, ably assisted by nursing staff, police and ambulance, was instrumental in minimising deaths and injuries but tragically 21 people lost their lives either during or following the fire.

The Quakers Hill Fire

At 4:53am on 18 November 2011, Fire and Rescue NSW (FRNSW) responded to an automatic fire alarm at the Quakers Hill nursing home in Sydney’s west.

FRNSW responded 20 fire appliances and nearly 100 firefighters to the fire. 88 aged, sick and frail residents were physically rescued from the building. There were four staff members on duty who also assisted with the evacuation.

Two fires were deliberately lit in separate wings. The first fire was minor and contained in an unoccupied room. The second fire was lit in an occupied room and spread throughout the wing.

A nurse working in the home, Roger Dean, was later convicted of lighting the fires resulting in the murder of 11 residents. He was sentenced to life without parole.

In 2013, the NSW Government made installation of automatic fire sprinkler systems mandatory for all nursing homes. Retrospective upgrades had to be completed no later than 1 March 2016, unless an extension to 1 March 2017 has been approved and granted.

Challenges for firefighters

Two separate fires caused initial confusion and delay, with both requiring separate intervention.
Dense smoke descended down to 50cm above the floor in the ward resulting in zero visibility.
Some residents sought shelter under beds or behind furniture making them difficult to locate.
The alarm and building occupant warning system made communications difficult during the evacuation.
Ceiling collapse created obstacles for rescuers.
Mass rescue resulted in congestion at exits, particularly from moved beds. Many residents had to be carried from their beds at the exits.
Fire/smoke doors in ward were opened as rescue took place allowing dense smoke to enter the corridor and adjacent wards.
Resources in the initial stages were very limited and casualties could not receive initial care.
Lack of Triple Zero ‘000’ call to confirm fire resulted in delay to escalated response.

Lessons for care facilities

Upon activation of fire alarm, staff should immediately check the source of the alarm to confirm the presence of smoke or fire.
If fire is confirmed, it is vital that at least one person calls Triple Zero ‘000’ so FRNSW can immediately respond more resources.
Staff must immediately begin staged evacuation starting with those at greatest risk of harm.
Staff must ensure fire/smoke doors remain closed to reduce fire and smoke spread.
Mobile residents should be gathered in a safe area, then escorted to the assembly area if required by the nature of the emergency.
Non-ambulant residents should be moved in accordance with your emergency plan. In extreme situations residents may need to be carried or dragged to safety.
During evacuation, passageways must be kept as clear as is reasonably practicable.
Fire exits and other doors must be kept clear of obstructions at all times.
Staff must give clear concise instructions to residents during the evacuation, including visual gestures when background alarms make verbal communications impossible.
The emergency plan must consider the evacuation of non-ambulant patients, such as those connected to medical equipment.
Regular training and evacuation drills should be undertaken by all staff, including practicing urgent removal of non-ambulant residents.

Emergency Planning

Owners and operators of care facilities are responsible for ensuring adequate emergency planning and preparedness is undertaken.

Australian Standards AS 3745-2010 Planning for emergencies in facilities and AS 4083-2010 Planning for emergencies - Health care facilities should be used when planning for emergencies.

FRNSW recommends all aged care facilities and places providing accommodation to persons who need physical assistance (e.g. disabled), comply with NSW Health Policy Directive PD2010_024 Fire Safety in Health Care Facilities.

The emergency plan must identify the person in charge during an emergency (e.g. Chief Warden) as well as other staff with specific procedures to follow during an emergency (e.g. Wardens).

The plan should identify the prioritisation for evacuation (i.e. staged evacuation process).

All staff should receive emergency response training at least once every year.