H.—7a.

Now we, the undersigned, respectfully submit for Your Excellency's consideration the following 1 report of our proceedings and of the opinions we have formed in respect to the several matters and things we were directed to inquire into: — As the matter was one directly involving the public interest, the police readily acceded to the request of the Commission that evidence of witnesses of assistance to the Commission should be obtained by the police and placed before the Commission. The Commission discussed fully with the police on different occasions prior to the hearing the evidence the Commission desired placed before it, and in particular the expert evidence that should be called. The Mental Hospitals Department was notified of the dates on which the Commission proposed holding sittings. Similar notification was given to the relatives of all the patients who had lost their lives. The Commission took the opportunity, prior to the hearing, of inspecting the site of the fire and the buildings comprising Seaeliff Mental Hospital. Miss Tomlinson carried out a personal inspection of the routine adopted for supervision by nurses of the female patients, particularly during the night. Mr. Laidlaw made a thorough inspection of the fire-alarm system and the fire-fighting appliances. At this stage it may be convenient to mention that the Commission did not inspect the Orokonui Home, which forms part of Seaeliff Mental Hospital, but which is situated at Waitati, a distance of about six miles, and the discussion as to buildings and fire-fighting appliances, &c., apply only to the mental hospital situated at Seaeliff and not to the subsidiary buildings at Waitati, nor to the buildings at Puketeraki. The Commission opened its sittings at the Courthouse at Dunedin on Friday, 15th January, 1943, at 11 a.m., and continued on Monday, the 18th, and Tuesday, the 19th January, and Thursday, 21st January. The hearing was then adjourned to 22nd February, 1943, when further evidence was taken and the sittings concluded. The proceedings were open to the public, and the press was present on each day of sitting. On the opening of the Commission the Chairman stated that the Commission desired to have all material evidence placed before it. Chief Detective Holmes appeared on behalf of the Police Department, Mr. F. B. Adams for the Mental Hospitals Department, Mr. I. L. Turnbull for the Public Service Association, and Mr. Rutherford for the Vigilant Automatic Fire Alarm Co., Ltd. Mr. McLean and Miss Watkins acted as official stenographers to the Commission throughout. In all twenty-six witnesses were examined, and a copy of the evidence is attached to this report. A large number of photographs of Seaeliff Mental Hospital were taken by the official police photographer. These and other exhibits are not attached, but have been retained by the Commission. They are available and can be forwarded if required. We deal with the matters submitted in the order of reference. In referring to " Ward 5 " it is understood that we refer only to the wooden building which was wholly destroyed by fire and not to the brick building which was connected by a stairway with the wooden building. The brick building is officially known as part of Ward 2:— (1) Was the building known as Ward 5 of the Seaeliff Mental Hospital or any part thereof dangerous in respect of fire hazards having regard to the number of persons accommodated therein, f We are of the very definite opinion that, irrespective of the number of patients accommodated therein, Ward 5 was dangerous in respect of fire hazard. (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 f We are of the opinion, that danger in respect of fire hazard was due to the original design of building, which did not make proper provision for protection from fire. The ward was a two-storied wooden building and was wholly constructed of wood. The wooden floors were waxed. Also, as stated by Mr. Mandeno, " the space above the ceiling and the rafters was uninterrupted from end to end, and that once the fire obtained a hold it would very rapidly sweep through the full length of the building." Sleepingaccommodation consisted of ten single rooms on the ground floor and a dormitory of twenty beds and nine single rooms on the first floor. The windows of all rooms were shuttered and opened with a key from the inside, and all patients in single rooms and the dormitory were locked in at night. There were no fireplaces in the ward, which was heated by steam pipes. We find it difficult to think the design of such a building, even in 1908, would have been approved by a competent architect. The evidence before the Commission was that it was designed by the then Superintendent of the Seaeliff Mental Hospital (the late Sir Truby King). The danger owing to the faulty design was in our opinion greatly increased by the fact that no automatic fire-alarm was installed. There was a manual fire-alarm, but, as referred to later, this could not be operated except by a nurse. Obviously also the danger was further increased by the fact that no nurse was in Ward 5 continuously; it was visited hourly. (3) Was the fire-alarm system adequate, regularly and sufficiently maintained, inspected, and tested and in proper order at the time of the fire ? The main fire-alarm system installed at Seaeliff Mental Hospital is an electrical system depending wholly on manual manipulation. It is a push-bell system. In all wards to operate push-bell a shutter must first be unlocked. Each nurse has a key to open any alarm shutter in female wards, and each male attendant one to open any in male

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