H.—7a,

1943. NEW ZEALAND.

COMMISSION UPON FIRE AT SEACLIFF (REPORT OF).

Presented to both Houses of the General Assembly by Command of His Excellency.

To His Excellency Sir Cyril Louis Norton Newall, Marshal of Our Royal Air Force, Knight Grand Cross of Our Most Honourable Order of the Bath, Member of Our Order of Merit, Knight Grand Cross of Our Most Distinguished Order of St. Michael and St. George, Commander of Our Most Excellent Order of the British Empire, on whom has been conferred the x\lbert Medal of the First Class, Governor-General and Commander-in-Chief of the Dominion of New Zealand. May it please Your Excellency. Whereas by Warrant dated 23rd December, 1942, under your hand and sealed with the public seal of the Dominion of New Zealand we, the undersigned, were appointed a Commission to inquire into the circumstances attending the fire which occurred upon the night between Bth and 9th days of December, 1942, at the Seacliff Mental Hospital, whereby the portion of the building known as Ward 5 was completely burnt and thirty-seven patients lost their lives, and in particular to inquire into and report upon the following matters:— (1) Was the building known as Ward 5 of the Seacliff Mental Hospital or any part thereof dangerous in respect of fire hazards having regard to the number of persons accommodated therein? (2) If so, did such danger exist by reason of any defect in design, construction, material, equipment, or furnishing of the building or for some other reason; and, if so, for what reason? (3) Was the fire-alarm system adequate, regularly and sufficiently maintained, inspected, and tested and in proper order at the time of the fire? (4) Was the fire brigade of the institution efficiently trained and effectively used on the night of the fire? (5) Were the fire-fighting appliances of the institution adequate in respect of hydrants, lengths of hose, and any other necessary appliances and adequate in respect of water-pressure, and in other respects, and were the appliances regularly and sufficiently maintained, inspected, and tested and in proper order at the time of the fire? (6) Was the supervision of patients by the staff of the institution at all times of the day and night and in all respects adequate? (7) Was there on the part of any member of the staff a dereliction of duty that contributed to the deaths of the patients or any of the patients ? (8) How did the fire originate and spread, or probably originate and spread? (9) Are there any practicable steps that should be taken to reduce the fire hazards of the institution and similar institutions so as to avert the risk of occurrence of fire, risk of spread of fire, and risk of loss of life ensuing therefrom ? And generally upon such other matters arising thereout as came to our notice in the course of our inquiries which we consider should be investigated in connection therewith and upon any matters affecting the premises which we consider should be brought to the attention of the Government: And whereas by the said Warrant we were required to report to Your Excellency in writing under our hands and seals not later than the Ist day of March, 1943 (which date was later extended to the 15th day of March, 1943), our findings and opinions on the matters aforesaid, together with such recommendations as we should think fit to make in respect thereof.