Key expertise in the case of hospital patient who died in fire strapped to bed
He was aggressive so the staff of the hospital in Kutno tied him to the bed, which an hour later burst into flames. Today, the prosecutors know that cigarette flame had caused the fire. Who is responsible for the tragedy? This mystery may never be solved as the patient who shared the room with the 37-year-old that fateful night, has died.
The terrible accident happened at night between 11 and 12 March in a hospital in Kutno. A hospitalised 37-year-old man was very roused, according to the staff. Forty five minutes after midnight, the employees tied the man to the bed with safety straps. At 1.40, the bed was set on fire.
The staff extinguished the fire and untied the patient. He had burns on 70 percent of his body and died a few hours later at an intensive care ward.
Prosecutor’s from Kutno investigating the case have just received a key expertise by firefighting expert witness, who has determined what caused the tragedy.
"According to the opinion, most likely the fire was sparked by one of the persons from the ward," the Regional Prosecutor in Kutno, Piotr Helman, told tvn24.pl.
The expert witness added that the bed was put on fire by a spark from a cigarette or a cigarette butt that was dropped on flammable materials - bed linen of mattress.
According to the investigation documents, the 37-year-old was in a very poor mental state.
"He is said to have used vulgar words, demanded a cigarette and threatened the personnel. His behaviour suggested that he may have had hallucinations and wanted to leave the hospital. He wasn't sure where he was," said Piotr Helman told tvn24.pl.
At night between 11 and 12 March, there were four women working the at the shift - three nurses and a doctor. "The women asked A&E workers to help them to calm the patient," the head of the hospital, Andrzej Pietruszka said.
Before 1 am, the man was tied to the bed with security straps in a two-bed room number 11. By the time he got strapped, he already received tranquilizers. Next, in line with the health ministry order from December 21, 2018, that the hospital is quoting, the staff drew up a "coercive measure card" for the patient.
The form was filled in by a nurse. She was legally bound to check on the patient every 15 minutes and make sure that the straps weren't loose and if the patient was safe.
In the documents, signs of three such visits were recorded: at 1.00, 1.15 and 1.30. At 1.40, a 71-year-old man ran out of room 11. He was woken up by the screams of the patients in the burning bed.
As we've learned, the 37-year-old was tied with safety straps fitted with emergency unlocking system. Due to high temperature, however, the device failed to work.
Witness is dead
According to the expert witness' opinion, the source of the flames was located in the upper-right side of the bed. Next to the bed on the floor, an open pack of cigarettes was found, whereas on the mattress, a burned-up lighter.
The prosecutor's office is trying to determine if the 71-year-old could have lit a cigarette for the strapped patient and placed it in his lips.
"Shortly after the accident, the man was questioned as a witness. He said that he had nothing to do with the fire. He also stressed that he had been sedated that night," prosecutor Helman added.
The 71-year-old cannot be questioned again as the man died in April this year. It means that, most likely, no one will be charged with causing the fire.
"At this point we have no doubts that no one from the staff was responsible for the fire," Piotr Helman said.
Question of supervision
That doesn't mean, however, that the investigation has been discontinued. The investigators are examining the question of the staff supervision over the strapped patient.
After the tragedy, the head of the hospital summoned a team to explain the circumstances that caused the accident. The works of the commission ended with a conclusion that it was necessary to install smoke detectors at the internal wards.
"We have done that already. Apart from that, we've made sure to have a transport team available, so that it would be ready around the clock to take patients to a specialised clinic," Andrzej Pietruszka said.
He added that the commission had not found any malpractice on the personnel part.
"We're waiting for final opinion of the prosecutors. At this moment I can say that we've done everything to prevent such tragedy from happening again. What happened in March was a disaster for us. I apologise that it happened," director Pietruszka told tvn24.pl.