London Fire Brigade (LFB)/NHS Concordat Seminar
LFB Headquarters, Southwark - 30th September 2015
Click the ‘Slides’ link after each session’s title to view the slides for that session - the file type and size are shown after the link.
Click the ‘Profile’ link after each speaker’s name to read their profile.
Click the 'Q&A' link after each speaker's name to view questions asked and answers given.

1 – Welcome (Slides - PPTX, 511Kb)
AC Neil Orbell, Fire Safety (Statutory & Community), LFB | Q&A

AC Neil Orbell opened the day by noting that the LFB/NHS Concordat is now 10 years old and that, of the 117 fire incidents recorded in healthcare buildings last year, 95 did not require the use of LFB fire fighting equipment.

There has been an 81% reduction in unwanted fire signals (UwFS) since monitoring began in 2006 with some sites reducing their UwFS from 120 a year to none. AC Orbell noted that this has been largely due to the well-maintained and monitored fire alarm systems and, while he congratulated his NHS colleagues on this achievement, he urged them not to become complacent and to maintain the same quality of service going forward.

Since LFB started charging for UwFS early in 2014 there have been a number of appeals challenging the decision to charge for certain calls, particularly involving the legitimate use of break glass points by staff members or members of the public. AC Orbell noted that each appeal is treated individually and the Trusts in question should have received a ‘holding letter’ while LFB thoroughly investigates the circumstances of the call and the appeal. NHS organisations were reminded that they should keep thorough records of UwFS to help with this process. As part of their investigation, LFB will consult with the team attending the call to assess their reasons for recording an UwFS in each instance. Once they have completed this process LFB will contact each Trust direct to inform them of the outcome of their appeal.

2 – False Alarms - A Manufacturer’s Perspective (Slides - PPTX, 7.8Mb)
Mark Dawson, Key Account Manager (UK Sales Team), Apollo Fire Detectors Ltd | Profile | Q&A

Mark Dawson reviewed Apollo’s company background and history. He then talked about how important it is to select the correct type of detector for any given situation. Apollo offers a full range of detectors to suit every need and they have recently added the Soteria detector to their range that uses their new CoreProtocol technology. A flush version of the Soteria detector will be released early in the New Year that is designed for custodial environments and features an anti-ligature, anti-vandal design.

3 – Future of the Concordat (Slides - PPTX, 213Kb)
Phil Gibbs, Inspecting Officer & Hospital Team Manager, Business Support Group, LFB | Profile | Q&A

The Concordat agreement was set up 10 years ago as an informal agreement between LFB and NHS Trusts in London to work together to improve standards of fire safety in healthcare. It was intended to be a template for use in regions throughout the UK but only London actually went ahead in the end. Set up primarily by Phil Smith, then of NHS London, the Concordat has been useful in implementing the requirements of the Regulatory Reform (Fire Safety) Order 2005 (RRO) in 2005/6 and in significantly reducing UwFS through the sharing of knowledge and good practice. The core members of the Concordat are representatives from NHS Trusts in London, NHS Property Services, Community Health Partnerships and LFB along with invited guests from other representative healthcare associations.

As a founder of the Concordat, Phil Smith suggested that it was time for the written Concordat to go. When NHS London was disbanded, LFB took on the organisation of the Concordat meetings to ensure they continued. Phil suggested that the Concordat should consist of representatives from NHS Trusts, the Trust Development Agency (TDA) for non-foundation Trusts, Monitor for Foundation Trusts, the Care Quality Commission (CQC) and NHS England as parties with an interest in improving the quality of Fire Safety in NHS properties. It should be noted, however, that the TDA and Monitor are soon to merge to become NHS Improvement. Phil suggested that whatever decision is made regarding the future of the Concordat, it should be communicated to NHS England for inclusion in their documents and newsletters.


The Concordat currently meets twice a year to discuss specific topics and once a year for the Concordat meeting itself. The larger annual meeting requires a good 4 or 5 meetings between LFB and 2 or 3 representatives from NHS Trusts to organise plus supporting admin work, something LFB are not funded to do.


The proposal is to retain the annual Concordat meeting but merge the NAHFO London Branch meetings with the themed events. LFB attend the NAHFO Branch meetings anyway so the link will be maintained. A question was posed to the audience – If the written agreement is removed, would it make any difference if NAHFO London Branch is arguably a better forum anyway? LFB asked for suggestions to be put forward regarding the future of the Concordat.

4 - Fire Safety in Multiple Occupancy NHS Premises (Slides - PPT, 1.3Mb)
John Brett, Head of Health, Safety, Security & Fire (London), NHS Property Services Ltd | Profile | Q&A
Paul Digby, Area Health, Safety, Security & Fire Mgr, (NW London), NHS Property Services Ltd | Profile | Q&A

When the RRO was introduced in 2005/6, Primary Care Trusts (PCTs) were employers/landlords and therefore identified as the ‘responsible person’. With the advent of the Health and Social Care Act in 2012, PCTs moved under the ownership of NHS Property Services Limited (NHS PS), a government-owned private limited company formed to act as a commercial landlord and advise former PCT staff of their legal responsibilities and how to meet them.

After PCTs moved under NHS PS control, NHS PS found that just 25% of them had a formal agreement for their tenancy. The move of PCTs to NHS PS confused matters by shifting responsibility for meeting the RRO’s requirements to ‘occupying employers’. To confuse matters further, where NHS PS is in control of the common areas within a building, they conduct Fire Risk Assessments (FRA), maintain the fire alarm system, devise plans, and maintain appropriate policies and procedures. Also, where NHS PS has employees on site, they have a duty as an employer to ensure the safety of their staff.

Problems arise where the Lead Tenant within an NHS PS building does not fully understand their responsibilities and/or lacks the budget to take required measures. In such circumstances, NHS PS tries to clearly define their and their lead tenants’ responsibilities with reference to the RRO legislation. NHS PS always tries to promote co-operation between tenants on their sites and encourage the lead tenant to adopt the role of co-ordinator.

5 – Approved Inspections & Building Regulation Inspections (Slides - PPTX, 6.9Mb)
Paul Robinson, Harwood Building Control Approved Inspectors Ltd | Profile

This presentation covered the history of the Building Regulations and looked in detail at their purpose in setting minimum standards for the design, construction and alteration of virtually every building. After looking at some of the alternative standards documents available – British Standards, HTMs and Building Bulletins for example – and the many Competent Person Schemes for various aspects of building work. The presentation then covered instances when you would (or wouldn’t) need to apply for Building Control approval and what the process involves.

6 – Royal United Hospital ITU Fire, Bath (No slides available)
Dr Mark Turner, Senior Anaesthetic Registrar, Southmead Hospital, Bristol | Profile

This presentation was delivered at the NAHFO National Conference in May 2015 in Blackpool. This incident occurred at the Royal United Hospital in Bath, a large DH with 565 beds, on the evening of 22nd November 2011.

Dr Turner provided a comprehensive account of events leading to the ITU fire he witnessed including how the fire developed, the probable cause, the events that followed and the outcome of the incident.

7 – Salvage Considerations – Who’s Responsible? (Slides - PPT, 1.5Mb)
Paul Bishop, Chairman of NAHFO London Branch & Fire Safety Manager, Royal Marsden NHS FT | Profile | Q&A

The guidance for the salvage of equipment following fire incidents is unclear. Following the evacuation of patients, equipment of high value – either financially or in terms of importance to the Trust – must be both identified and its physical location noted and tracked. Pre-planning and accurate record keeping is vital to the success of any salvage operation. The slides for this presentation cover these considerations in more detail.

For areas of critical importance, contingency plans may be in place. For example, a stem cell research lab may have a ‘dormant contract’ that only kicks in when the on-site facility is compromised by a fire or other incident. When this occurs, vital stem cell storage units are removed and securely relocated so that no material is jeopardized.

8 – Fire Door Maintenance: A Risk Based Approach (Slides - PPTX, 1.8Mb)
Mazin Daoud, Fire Safety Engineer, Sodexo ‘Quality of Life’ Services | Profile

A number of items of guidance including the RRO Article 17, HTM, British Standards, Best Practice and manufacturers guidelines refer to the frequency of maintenance of fire doors (how and when it should be done).

If you were to adopt a risk-based approach to fire door maintenance, how often should you maintain your fire doors? You must state this frequency and why your have chosen to deviate from the guidance.

As a starting point, think about the purpose of the fire door. It is to stop fire and protect escape routes in buildings. HTM05-03 Part K states that fire doors should be visually checked on a monthly basis and then fully checked annually. AS an example, one London hospital has 3,000 fire doors and another has 8,000, so clearly monthly checks are not sustainable. BS9999 suggests a six monthly check of all doors regardless of use and location.

The frequency of checks should also factor in the location of the fire door and how long it should last in the event of fire. For example, a ward kitchen door might be expected to last 30 minutes but an ITU door 60 minutes.

Thought should also be given to the frequency of use and the increased likelihood of damage to fire doors as a result. For example, the entrance to a busy ward is likely to get heavily used and abused.

One way to draw up a suitable risk-based maintenance strategy is to devise a simple 3 by 3 matrix with criticality (based on 3 levels of patient dependency) along one side and usage (based on 3 levels of door use) along the other. The intersection the criticality and usage ratings will define the frequency of maintenance (monthly, 3 monthly, 6 monthly or annually). The likelihood of damage from frequent use should also be factored into this and the maintenance frequency increased where the likelihood of damage is higher. For example, a low usage fire door protecting an independent patient on a ward might be checked annually but a high usage fire door protecting a ward with high dependency patients might be checked monthly. Refer to slides for an example.

It was suggested that NAHFO should devise a standard set of PPM maintenance schedules for typical hospital equipment and share them with local Enforcement Authorities. These could then be used as a starting point and adjusted for local use and damage susceptibility.