There were “systemic failures at all levels” and the persons in charge of the Drop-In Centre (DIC) are collectively responsible for the state of affairs that led to the deaths of two young brothers in a fire at the centre in July, a Commission of Inquiry (CoI) has found.
“The CoI found that this was a tragedy waiting to happen and that there was collective responsibility for the tragic event which claimed the lives of Joshua and Antonio George. The system to protect the children failed and therefore all the players are collectively responsible,” the report said.
Among other findings, the report highlighted the overcrowding at the centre, the inadequate and poorly trained staff working at the time of the July 8 fire, and the lack of adherence to fire regulations.
“Because the child care system was not foolproof, failures will have catastrophic consequences. All participants must therefore be held accountable for their own stewardship and for those under their control,” the report declared.
It said the COI was able to definitely determine that Joshua George and Antonio George died as a result of smoke inhalation, but the remaining 29 children and two staff did not sustain any physical injuries. According to the report, too, some of the older girls were still traumatized as a result of the tragedy. It said they blamed themselves for the deaths of the two children and were often having flashbacks and not sleeping well at night.
President David Granger had set up the CoI, which was headed by retired Colonel Windee Algernon, to investigate, examine and report on the causes, conditions and surrounding circumstances that led to the deaths of Antonio George and Joshua George on July 8, 2016, while they were in the care, control and custody of the state.
The report was submitted on August 8 and while it said that those culpable must be held accountable, it did not recommend any disciplinary measures.
It found that the centre was overcrowded. According to the document, at the time of the fire there were 31 children housed in the building, but it could only have comfortably housed 21 children. The children at the centre that night ranged in ages from 17 to under one year, seven months old. The girls and the younger boys (under five) were housed on the top flat of the building, whilst the boys were on the lower flat. There was one exception, an 11-year-old boy, who was housed with the girls because of his small stature, the report said.
Further, there was inadequate staff rostered to work on the night of the tragedy which was in direct contravention of the Minimum Operational Standards and Regulations (MOSR) for children’s homes in Guyana.
“Using the children/staffer ratio a minimum of six SSAs (social service assistants) should have been on duty to adequately meet the needs of the children. However, on the evening of the fire, there were only two SSAs on duty,” the report said. It noted that while the House Services Supervisor Claudette Mentore had the authority to call out additional staff, she failed to do so for no valid reason.
Additionally, the CoI found that while there were adequate written guidelines for the management of crisis situations including fire, those on duty that night and other top officials were not familiar with them. “Thus, when the fire occurred there was confusion and panic resulting in the tragedy,” the report said.
The CoI also found that the assistants on duty at the time did not possess the necessary qualification and experience for the responsibility given to them. “According to the MOSR qualifications for the position of a SSAs (Care-givers) is a Diploma in Social Work, Sociology and three years’ experience working with children, or a Trained Teacher’s Certificate along with a valid police clearance or a secondary education and ten years’ experience caring for children,” the report said.
Further, the report said that the centre did not comply with all fire regulations. “There were no operational fire escapes, no smoke alarms, no marked fire exits and signs on the wall stating what to do in cases of fires,” the report declared. It said while there were fire extinguishers and fire blankets on both floors of the centre, the children and SSAs on duty—Sharon Jones and Rupert Hinds—were not trained to use the fire extinguishers nor the blankets.
“It is the determined view of the CoI that if proper fire safety practices were implemented the fire would not have occurred and there would not have been the loss of life,” the report said.
It had noted that the CoI found that the fire was caused by a defective electrical point fitted with exposed wires in the girl’s dormitory which played a role in the fire ignition and which caused the fire to travel through the electrical conduits in the ceiling.
Further, the inquiry found that following a fire of similar origin at the centre, recommendations from the Guyana Fire Service in 2010 and 2015 were not fully implemented.
The report said that the conduct of the staff on duty on the night of the fire was not in conformity with the required statutory obligation of the State and Standard Operating Procedures (SOPs). “The CoI unearthed an absence of understanding and rehearsals of the SOPs for the handling of crises situations. Consequently they were not applied before or during the fire, resulting in an unplanned, ad hoc evacuation of the children at the DIC,” it said.
The report said that the SSA on duty at the time cannot be entirely absolved since two children died in her care. However, it pointed out that the centre as well as the Child Care and Protection Agency (CCPA) failed to ensure that the assistant possessed the skill set to perform her responsibilities adequately.
The report also said that both the Deputy Director of Policy and Development Ms S Fraser and the Manager for all the Care Centres Ms M Gentle should also be held accountable since they failed to ensure adherence by the Manager and Supervisor, to the SOPs governing human resource and protection from fire and other disasters and also failed to ensure that all the buildings which house Care Centres are maintained and secured. It also identified several failures of state officials.
Among other recommendations, the CoI has urged that emergency evacuation plans be developed and practiced at all child care facilities. “These plans must include safety protocols,” the report said.
In-house training including rehearsal in crises management at all child care centres, suitably qualified staff, the development of emergency evacuation plans and also the appointment of Inspector of Homes were among some of the recommendations by the commission.
It was also recommended that “the Ministry of Social Protection and the CCPA continue to focus on overhauling child protection, cutting red tape and improving the skills and knowledge of social workers so that they could adequately protect children in the state’s care.”
Also the commission recommended that the Ministry of Social Protection arrange and conduct inspections of all similar facilities nationwide.
