H.—7a,

wards. We are of the opinion that no such fire-alarm system can be considered adequate, as clearly proved by the fire on the night of Bth December, which gained alarming proportions before being detected by the nurse for the time being in charge of the ward or any other nurse or attendant in the vicinity of Ward 5. When the alarm was given the system functioned well and must have been in good order. The evidence showed that the system was regularly inspected and tested. We think that any system electrically controlled should be under the charge of a person with thorough electrical knowledge and that, so long as the present system be retained, a method be adopted of an automatic record of inspection and testing. We deal with the question of fire-alarms generally more fully hereafter under clause (9) of reference. Some of the workshops have an automatic fire-alarm which is connected with the main system. This portion of the installation is adequate and satisfactory. (4) Was the fire brigade of the institution sufficiently trained and effectively used on the night of the fire ? The fire brigade, on the evidence before us, appears to have been efficiently trained by the officer in charge (Mr. Driscoll) in the use of all equipment that was available. All witnesses agreed that it was effectively used on the night of the fire. In our opinion, the brigade carried out its onerous duties with great efficiency after the outbreak of fire was discovered and is entitled to great praise for the manner in which the fire was restricted to Ward 5 and was prevented from spreading to the adjoining wooden wards on the northern side, which were in grave danger. This was evident from the blistering and charring plainly visible. In this connection we desire to express our opinion that all members of the staff, from the Medical Superintendent down, displayed coolness, resource, and excellent organization in evacuating to places of safety all patients in wards in dangerous areas. (5) Were the fire-fighting appliances of the institution adequate in respect of hydrants, length of hose, and any other necessary appliances and adequate in respect of waterpressure 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 1 In order to combat the fire which occurred, in our opinion the fire-fighting appliances were adequate in respect of hydrants, length of hose, and first-aid appliances. The water-pressure was not, in our opinion, sufficient. The appliances were regularly and sufficiently maintained, inspected, and tested and were in efficient working-order at the time of the fire. Our finding in this connection is subject to modification that in our opinion the fire-fighting appliances, particularly in respect of length of hose, size of nozzle, and lowness of water-pressure, are not sufficient to combat a major fire liable to occur, and this aspect of the matter is dealt with more fully in our remarks in connection with clause (9) (infra). We also there refer to improvements in maintenance and care of branch pipes and general supply pipes, &c. (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 ? This matter has caused us great concern. At the present time Seacliff Mental Hospital, in common with all other mental hospitals, is experiencing a great shortage of staff, and in our opinion the hospital staff is inadequate in numbers to provide the requisite supervision of all patients at all times. We think that the arrangements made by the administrative staff for the supervision of patients during the day is adequate, but do not think that the number of nurses available can provide adequate supervision in all wards by night. With special reference to Ward 5, it is unfortunate that probably owing to the shortage of staff a nurse was not on duty in this ward at all times during the night. It was attached for inspection purposes to brick building (part of Ward 2). The nurse in charge of latter ward made a round of Ward 5 hourly. Every two hours a round of all wards was made by Charge Nurse. An hourly visit does not appear to us sufficient to provide opportunity to adequately supervise all patients at night in a two-storied ward containing thirty-nine patients. (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 t There is no evidence before us of any such dereliction of duty. (8) How did the fire originate and spread or probably originate and spread ? Before attempting to answer this question we think it proper to refer to the evidence of witnesses who had been in Ward 5 or had passed it between 8 p.m. and the time fire was discovered. The evidence of Sub-Matron Little, Matron on duty, was that, accompanied by Nurses Baldwin and Ward, she visited Ward 5 shortly after 8 p.m! All the patients, thirty-nine in number, were then in bed and there was nothing unusual in the ward. Nurse Blythe commenced duty at 7.40 p.m. attached to Ward 5, and was present in Ward 5 during Sub-Matron Little's inspection. She was relieved about 8.30 p.m. by Nurse Boyd for forty minutes and went to the nurses' home during that period. Nurse Boyd stated that while on relief she commenced observation round of Ward 5 at about 8.50 p.m. Her inspection took about five minutes. Nurse Boyd and Matron McLaren were recalled regarding length of time it would take to make inspection, and the Matron was of the opinion that inspection could not be carried out in five minutes. The time taken by Nurse Boyd can be taken as an approximation. On this inspection everything

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