B1/2007Y Fire at Pitkäniemi Hospital in Nokia on 25 January 2007
The Pitkäniemi hospital raised a fire alarm on 25 January 2007 at 11:18 p.m. Outdoor clothing hanging in an open wardrobe located in the corridor of acute psychiatry ward APS 9 had caught fire. Though the fire was detected at an early stage, attempts by the staff to put it out were ineffective, because the clothes in the wardrobe burned easily and created an ample supply of flammable gases. Heat caused fire gases close to the ceiling to catch fire, resulting in rapid and violent escalation of the fire to inner parts of the building, while ample and toxic fire gases limiting visibility spread to all corridor areas as well as patient rooms. In this difficult situation, the staff managed to evacuate 10 of a total of 18 patients, and the fire brigade rescued the remaining eight.
Department APS 9 was located in building 17 of the Pitkäniemi hospital, caring for patients suffering from long-term illnesses. The psychological status of the patients and sedative medication administered to them complicated the evacuation carried out by the nurses in a situation in which their own safety was at risk. In addition, the fire brigade rescuers experienced difficulties in trying to communicate with the ill and medicated patients.
In total, 18 people were injured in the accident. Of these, 15 were patients in the APS 9 ward, two were nurses from the same ward, and one was the head night nurse of the hospital.
The material damage came to approximately EUR 500,000. The police performed a fire cause investigation for the accident site, based on which the fire was found to have been started with a match by one of the patients. On the basis of the accident investigation, the following issues, alongside others, were found to have contributed to the creation and escalation of the accident. Information on the patient’s inclination to start fires had not been communicated to the nurses on duty on the APS 9 ward. Ignition of the fire was enabled by the established practice of storing clothes on the ward. Storing clothes in a completely or partly open rack in the corridor created a fire risk that had not been recognised. Had the building been equipped with an automatic fire extinguishing system, the fire would have gone out before spreading outside the wardrobe.
A serious accident was avoided because all of the following occurred during the incident: 1) The fire was detected almost immediately by the head nurse who coincidentally arrived at the place where the fire was ignited. Extinguishing attempt and evacuation began without delay and the fire brigade was alerted immediately. 2) The staff managed to evacuate 10 patients after the extinguishing attempts even though the conditions developed life-threatening and difficult in 2–3 minutes. 3) Despite the great power of the fire, the amount of fire load was minor, rendering the intensive phase of the fire quite short. 4) Thanks to the operations of the fire brigade, the eight patients still inside the hospital were rescued at the last minute.
To avoid similar accidents occurring in the future, the Pirkanmaa hospital district has decided to equip the Pitkäniemi hospital with an automatic extinguishing system by the end of 2008.
The Investigation Commission issues five recommendations, related to 1) the development of patient legislation to improve safety, 2) the drafting of risk management instructions for nursing homes and other nursing institutions, 3) equipping nursing homes and other nursing institutions with an automatic sprinkler system, 4) drafting of target-specific overall response times, and 5) improved fire safety for storage of outdoor clothing. A dissenting opinion concerning automatic sprinkler systems left by a member of the investigation commission is at the end of the report.
Video clips based on simulation of the first 7 minutes of the fire
Actual situation, no sprinkler system: