Documents cite critical lapses on night of nursing home fire
In depositions, fire officials tell of chaos, miscommunication

What's at issue?

A 16-minute delay in sending reinforcements

The incident commander called for a second alarm, but the 911 dispatcher did not immediately send more units.

First fire units arrived unsure there was a real fire, spent four minutes donning gear

The security firm notified dispatchers that the fire was real, but the information was not relayed to firefighters on the scene.

By HOLLY EDWARDS

The Tennessean
Wednesday, 02/23/05

Metro District Fire Chief Wayne Jackson arrived at the scene of the deadly nursing home fire and immediately called for reinforcements. But amid the confusion and communications mix-ups, the additional firefighters weren't dispatched for 16 minutes, causing a crucial delay as the National HealthCare Corp. nursing home filled with poisonous smoke and gases.

The fire was contained, but the smoke was spreading rapidly, and Jackson said he needed more men to evacuate the residents.

In a report on the incident, Jackson said he was concerned ''about the time lapse from when I asked for the second alarm until (firefighting) companies actually arrived on the scene.''

The dispatch delay was among a myriad communication problems revealed after more than a thousand pages of court records were unsealed yesterday following legal motions filed by The Tennessean and Metro government.

In depositions taken for dozens of civil lawsuits filed by fire victims, Jackson and other Metro fire officials describe a scene of chaos, confusion and danger on Sept. 25, 2003, as they raced to find the source of the fire and evacuate the elderly residents trapped in their rooms.

At least 16 of those residents died in the blaze or later as a result of their injuries.

The first firefighters to arrive at the scene weren't even sure there was an actual fire at the facility. They arrived just as an NHC employee was calling the dispatch center to report that it was, in fact, a real fire, the court records show.

But that message never reached the firefighters. It would be four more minutes before the first firefighters were equipped to begin tackling the blaze, according to the court documents.

Seven elderly women died the night of the fire, unable to escape after a blaze erupted near a bed in Room 221 on the second floor. Nine others died of their injuries in hospitals.

Metro Law Director Karl Dean said the Fire Department has reviewed every detail of its response to the fire. Several changes to methods of communication and firefighter equipment were made as a result, according to court documents.

''It's easy with 20-20 hindsight to say they should have done this or that, but they did the best they could and they saved a lot of lives,'' said Dean.

In court filings, NHC has said the Fire Department's mistakes and lack of training increased the deaths and injuries resulting from the fire.

NHC attorney David King said the records released yesterday paint a picture of heroic actions by the firefighters but serious flaws in the Fire Department's methods.

''The concerns raised about the Nashville Fire Department in no way detract from the heroism and significant efforts of individual firefighters,'' he said. ''The focus should be on the department's training, planning and operational procedures.''

For the firefighters responding to the blaze, the problems they encountered were unprecedented, Dean said.

The first firefighters at the scene tried to enter the second floor hallway to find the source of the fire but had trouble getting in because there was a woman on a bed blocking their path, Jackson, the district fire chief, said in court records.

That woman was Opal Askew, a resident of Room 221. NHC employees told investigators that they rolled Askew into the hallway before they tried unsuccessfully to put the fire out with fire extinguishers. After failing to put out the fire, they ran, leaving Askew where she was.

The other resident of the room, Anna Tolston, was in her bed engulfed in flames and pleading for help, employees told investigators.

Firefighters said when they looked down the second floor hallway from the staircase, they could see the fire in Room 221. But when they crawled down the hallway to find it, the smoke became too thick for them to see.

''They couldn't see, they were feeling their way, they were crawling on the floor,'' Jackson said in his deposition. ''They knew where the fire was, but once they got in there, they couldn't find it.''

Jackson also said the evacuation could have proceeded more quickly had someone at the facility had a key to unlock the elevators. But, he said, the elevators couldn't be unlocked until an NHC maintenance employee arrived.

By 11 p.m., firefighters were dealing with a host of problems ranging from communication glitches to missing firefighters. Multiple radio channels were being used by the firefighters and many messages were lost — including calls for help coming from two firefighters lost in the building, according to the records.

Meanwhile, the exhausted firefighters, many suffering water and oxygen shortages in intense heat and smoke, brought each resident out one by one down staircases and through windows.

Until this week, virtually all records in the 32 lawsuits filed against NHC were sealed under a judge's orders. Thirty of the cases have been settled in confidential agreements.

Metro attorneys and The Tennessean filed motions demanding that the records be made public.

Judge Barbara Haynes ordered the release of all depositions and reports related to the Nashville Fire Department but has not yet released records of statements by employees of NHC and the Tennessee Department of Health, which oversees nursing homes.

Haynes said in a hearing earlier this month that the depositions of state health employees also would be released yesterday, but NHC attorneys argued last week that they should be withheld until they finish all of the depositions of state health employees. Metro attorneys and The Tennessean opposed the delay but the judge sided with the nursing home firm.

NHC also has opposed the release of the depositions of their employees, arguing that the release of the documents would hamper efforts to settle the remaining two cases and could prejudice the jury pool if the cases go to trial.

Haynes has not yet ruled on the release of those records.

Parties in the lawsuits also are bound by a gag order that severely restricts their ability to comment about the fire or the legal battles.

Holly Edwards can be reached at 259-8035 or hedwards@tennessean.com.

For additional information, including copies of the depositions made public under the records request, go to www.tennessean.com

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In the News Bureau: For information on efforts by the Tennessee Supreme Court to make it more difficult for parties in lawsuits to close information that deals with public health and safety and the administration of government, see “Sunshine Sunday and Sunshine Week” in TCOG’s News Bureau.

Fire stayed in one room, but smoke became killer

http://www.tennessean.com/local/archives/05/01/66200521.shtml?Element_ID=66200521

Fire origin still a question; some records remain sealed

http://tennessean.com/local/archives/05/01/66200522.shtml?Element_ID=66200522