MENTAL HOSPITAL FIRE

Grey River Argus, 20 January 1943, Page 6

MENTAL HOSPITAL FIRE

SEACLIFF BUILDING Not Very Suitable INQUIRY CONTINUED DUNEDIN - , Jan, 19. The inquiry was continued to-day into the Seacliff Mental Hospital fire in which 37 lives were lost. The commission comprises Mr H. W. Bundle S.M. (chairman), Miss J. A. Tomlinson (Lady Superintendent of the Dunedin Hospital) and Superintendent F. G. Laidlaw’ (of the Dunedin Fire Brigade. Henry Mandeno, architect, who, under the Inquiry Commission’s instruction, made an investigation, stated that the nature of the hillside was unsuitable for such buildings as Seacliff, and when world conditions permitted, the finding of another site should be considered. Refractory patients should be entirely housed in fireproof uildings, preferably of one storey, and opening into a walled yard. He considered that the building in which the patients had been housed was “unsuitable because it was of two storeys, and was constructed of timber. The floors were of timber, and were waxed so that a fire would sweep through them in a Very short time. It was also unsuitable because the alarm system was manual and not automatic, and the patients were locked in with shuttered windows, while no attendant was continuously on duty. 3he evidence available pointed to the fire originating in the roof. Sidney Ewen Kershaw, Public Works Building Inspector, said that he had, in 1939, reported to the Department on the unsatisfactory condition of the fire alarm system, but his report was evidently overlooked, though a request had subsequently been received for an estimate on the cost of nutting the whole system in crder. This work was prevented owing to a shortage of material in 1940. Witness said that the buildings were in a bad state, the main structure being a mass of cracks. There were quite a number of buildings out of alignment. The whole hospital was quite unsuitable for the purpose for which it whs being used. This was no reflection on the maintenance staff. Their’s was an impossible task. Cross-examined, witness said that if. was quite possible that “those higher up” to whom his reports had been made, had not agreed with his opinion, Ernest Young, electrical engineer, said that after an intensive investigation he believed that the conflagration had not been electrically caused. Sub-Matron Annie Catherine Little said that w'hen she and two nurses visited the ward just after 8 p.m. nothing unusual was visible, and the patients were all in bed. The mattresses were straw covered with waterproof sheeting. The patients had no chance of obtaining matches and witness had never known any to be found smoking in bed. The patients in this ward w'ere assisted in dressing which minimised the chance of concealing matches. Edna Ward, charge nurse, stated that about 9.45 on the night of the fire she was at the back of Ward 1 and thought she smelt burning. She/ sent another nurse to investigate and went to Ward 2 from which she saw Ward 5 on fire. She set the alarms She found it impossible to enter Ward 5. She helped to evacuate the patients from the other wards.

Eileen McEvoy, a nurse, said she had been told by a parent on the afternoon of December 8 that the radio was not functioning and witnesc tried to adjust it, but did not succeed. She pulled out the plug and then reported the matter according to practice. Gladys Yvonne Blythe, a nurse said that at 9.20 she went through the wooden portion of Ward 5 and there was no sign of fire. Mavis McKenzie Boyd, a nurse, said she began her observation round at 8.50 and was in Ward 5 for about five minutes, both upstairs and downstairs, making a proper inspection. All appeared to be in order. She left the wooden portion at 9, returning to her mess room until relieved by Nurse Blythe at 9.20. Witness went past the wooden portion of Ward 5 but saw nothing unusual. Kathleen Blackmore, office assistant, said that on returning from the Seacliff township between 9.30 and 9.40 she passed Ward 5 and saw nothing unusual. A strong wind was blowing. Arthur Driscoll, attendant at the hospital, said he was captain of the fire brigade. When he observed the lire, flames were right through the roof and the front portion was falling in. He tried the south end door to see if he could get in to save anyone but it was impossible because of the flames. He did not hear anyone calling out, but observed a window where there were no flames. He pulled a grating off with his hatchet and as he reached a woman who was inside I her nightdress and bed jacket caught alight but he brushed the flames out. Witness formed the opinion that there was ho chance of saving the building, and he concentrated his efforts on attempting to prevent the fire from spreading. At one stage there were four leads of hose on the fire, the pressure being about 501 b to the square inch. He considered the equipment operated efficiently. Detective-Sergeant Gibson said it was impossible to ascertain how or where the fire commenced. The most likely theory was that It was due to some electrical cause and to earth movements. The flickering of the Tights and all the circumstances pointed that way. Leslie Roy Joseph Osmond, deputysuperintendent of the Dunedin Metropolitan Fire Brigade, said the water rate and pressure of delivery were not sufficient to give the hard-hitting jets so necessary where a fire of bigger proportions than an ordinary cottage fire developed. Witness continued: “Ernst there is an amount of wooden construction which in an institution of this nature naturally presents a distinct risk. This could also apply to the main building, because the interior is composed mostly of combustible material, although the exteror, is of brick and plaster. Added to this the age of a number of the buildings would be a factor in the event of fire. At night time the locking or the doors and shuttering the windows presents a most difficult problem and one that has to be considered from all angles. There were some bad features in regard to the direction in which some of the doors opened, and this applied especially to the theatre and to a number of the corridors. Alternative means of escape were fairly well provided for.” He inspected the building which had moved from its original position, and he was convinced that this movement could cause an electrical fault, although if this did occur the fuses on the switchboard would blow, thus deadening the circuit affected. The personnel of the brigade consisted of the. officer in charge and all the attendants who were able to leave their patients and assist. “This method of staffing the brigade is very chancy,” said witness, “and does not tend to create efficiency.” The equipment was in fairly good condition. He considered the quality of the hose provided as not above second-class, while a quantity of it could only be granted as third-class.

The equipment available and the method of staffing the. brigade could be suitable for dealing only with small and medium-sized fires. Arthur Edmenson, chief engineer at Seacliff, said that when power was first obtained from the Otago Power Board the wiring was changed to iron conduits wherever’ there was a possibility of dampness, but a portionwas still encased by wood. Ward No. 5 was situated in probably the worst portion of the area that was slipping. There had been no trouble through short circuits. There was nothing in the nature of an automatic fire alarm in Ward 5, but there was an alarm inside the ward which could be operated by the use of a shutter key which was possessed by each member of the staff. Clarissa Eliza McLaren, matron of the Seacliff Hospital for the last 21 years, said that the .normal nursing staff numbered 112, but at present it was 39 short. Every ward was visited at least once every hour. Some of the patients smoked in the day room in this building before they retired. but they were not given matches.

James Shearer, works overseer at Seacliff for 22 years, said that D ward was the original hospital, which had been shifted to the present site from Dunedin in 1879. Other 'buildings had been erected from time to time, mostly of timber. In almost every case in which heating had been supplied it had been by open fire. The women’s No. 5 Ward, Ihe building which was destroyed in the fire, the witness said, had been erected in J 908, two-storeyed, constructed of timber and heating was supplied to the dining-room only by steam radiation. Three exits were on the ground floor and fire escapes on the upper storey. On the ground floor was a dining-room which was at the north end, then a corridor, then nine single rooms. The kitchen was on the south-west side* of the building on the ground floor. Also on the upper floor were a dormitary holding 2.1 beds and nine single rooms. Two years ago the north end had had to be jacked back two feet and reinforced by bolts. On the night of the fire, witness hurried to the scene on receiving a message. By that time the northern part had burned out. From this, he concluded that the fire originated in that portion of the building. Another build’.ng, the women’s No. 1 ward, had been removed in 1936 because of slipping ground making it unsafe. The women’s No. 2 and No. 3 wards had been removed for th a same reason. Fire \ had occurred in the No. 1 ward in 1938, the dining-room having been completely destroyed. The cause of this fire had not been established, but a previous fire in the workshop’s store had been attributed to the spontaneous combustion of .coal stored in the building. Dr. Malcolm Brown, medical superintendent at Seacliff, said that there had been no sign of panic. A strong southerly wind fanned the flames. Within a very short time there had been little left of the building. The work of the nurses could only be described as magnificent. A shortage of staff which had been brought about by war conditions had in no way affec+ed the staffing of ward No. 5, nor had it affected the patrol system at the time of the fire. Nurses were not supposed to keep continuously on patrol as long as they were at a central post On the night of the fire, the nurse in charge of ward No. 5 was in a room in the brick building adjoining, this being her post. There could be no objection to an automatic (fire alarm system which patients could use, but. some patients became very expert at •setting these off, even throwing shoes at them.

Dr. Gray, Dirctor-General of Mental Hospitals, said that he had occupied his present position for sixteen years. .Altogether he had had about thirty-five years’ experience of mental hospitals. “I would not be prepared.” Dr. Gray said, “to adopt a new system of fire alarms,- and to sclrap another system which has given effective service for thirty years, merely because another system had been invented in the year before. The witness. Kershaw, made the first condemnation of the existing system there had been, in a report from the Public Works Department, suggesting an entirely different system of fire alarm, which was to be incorporated with the installation of the automatic telephone system. Further consideration has been deferred because it was impossible under war conditions to get the necessary automatic telephone units.

Concerning Kershaw’s statement that he would wholeheartedly condemn the buildings at. Seacliff, and would evacuate them forthwith, witness said that he had had considerable experience of such plans. In 1925, the Government had promised that the mental hospital at Auckland would be evacuated in ten years, and for that purpose it had purchased an estate near Papakura. At the end of ten years, however, the Auckland Mental Hospital had more patients than before, and in addition the new hospital had 700 patients. “The question of abandoning Seacliff has been discussed by me and several Ministers,” Dr. Gray said. “It was recognised., that the time was coming when evacuation would be necessary.” In anticipation of evacuation he had had two wings at Seacliff demolished, witness said, and the Department accepted the views the witness, Mandeno, expressed concerning the buildings at Seacliff. "One would never contemplate such a building as Ward 5 to-day,” Dr. Gray adijed, "and it is a fact that for the last twenty years no two-storey buildings have been erected foi- sucn a purpose.” Witness said he did not think there was any objection if wooden buildings were constructed on the villa system, which provided for singlestorey buildings capable of accommodating' fifty patients, with ample exits. “It would cost not less than £1,000.000 to' abandon Seacliff and get another site elsewhere,” witness said. He agreed with the view that because of the slipping nature of the country the site at Sea.cliff was unsuitable for the erection of further substantial buildings, and new buildings were not being erected. Dr. Gray said that there were a number of buildings which would be regarded as very .bad fire risks, but these were all erected more than 20 years ago. Ward D at Seacliff was a very bad risk, i To the chairman, witness said that the main building at Waitati was bad, and ’instructions had been given to evacuate it.

He said.that he was quite satisfied with the system for the opening of fire alarms by the use °f shutter keys. This was the general practice at Seacliff. The staff had always had a keen and particularly efficient fire brigade. Questioned concerning the financial limits to which the Department could go. witness said that last year the expenditure on buildings amounted to £175,000. There was a limit to the amount of expenditure because of the storage of material. He was not stinted but had to observe certain reasonable limits. Witness also said that the system of hourly rounds was the general practice in mental hospitals in New Zealand and elsewhere. The Commission formally adjourned until to-morrow morning, the Chairman stating that it was proposed that the taking of evidence should be concluded.