HC-One Limited, who ran Arcadia Gardens Care Home in Glasgow, pled guilty to a health and safety at work breach committed in March 2017.

The procurator fiscal depute told Glasgow Sheriff Court that on 25 March 2017 a fire broke out at Arcadia Gardens Care Home and a resident, Carol Hughes, died in hospital later that day from injuries she had sustained.

Ms Hughes had been a smoker and from early March had started to spend extended periods in her bed.

A Care Inspectorate expert gave the opinion that this change in Ms Hughes’s circumstances should have prompted a review of her care plan and risk assessments. A review was not undertaken, and appropriate control measures were not put in place.

Had these risks been identified, they could have been mitigated by appropriate monitoring and ensuring that Ms Hughes was supervised while she smoked.

Once the fire began the fire detection system indicator lights showed zone 6, which corresponded with the kitchen and laundry area, as the location of the fire alarm activation.

Kitchen staff were initially evacuated before re-entering the building to investigate. Following a period of time, staff observed smoke building up beyond the corridor doors leading from the kitchen to the residents’ rooms.

The smoke was coming from Carol Hughes’s room which was in zone 12. Due to the level of smoke build-up within the corridor, staff were unable to access Ms Hughes’s room to assist with evacuating her from the building. She was taken from her room by firefighters who requested an ambulance.

The fire began within Carol Hughes’s room, most likely amongst bed linen or clothing worn by Ms Hughes. A lighter and e-cigarette was found on the bed. A second lighter was found on the floor close to the bed.

The investigation of the fire detection system found that the zone chart was inaccurate with Carol Hughes’ room showing on the indicator panel as part of zone 6 when the chart displayed this room as zone 12.

Had the correct zone and room been identified, staff could have attended at the location of the fire sooner. The loss of Ms Hughes’s life cannot be attributed to any delay which occurred.

Speaking after the sentencing, Debbie Carroll, who leads on health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS) said: “The death of Carol Hughes could have been prevented if HC-One Limited had suitably and sufficiently assessed the risks to her health and safety by having access to smoking materials whilst bed-bound.

“Their failure to maintain the fire alarm detection system, ensuring it could accurately identify the location of the activation, led to delay in getting to the fire.

“This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”