The Fatal Accident Inquiry (FAI) into the death of 14 people at Rosepark Care Home, near Glasgow in 2004, says that some or all of the deaths might have been avoided if a proper risk assessment had been carried out, and the findings acted on.
The comprehensive report by the local Sheriff Principle of South Strathclyde, Dumfries and Galloway, lists a number of precautions which include several references to the use of fire doors.
The fire was caused by an earth fault in an electrical distribution box in a storage cupboard.
"Had the doors to the cupboard been fire resistant as well as being securely closed, this might have avoided some or all of the deaths" the report states.
Other issues relating to fire doors highlight the importance of self-closing devices and the installation of smoke seals.
"It would have been a reasonable precaution for all bedroom doors to have been closed in the event that a fire alarm sounded. In particular it would have been a reasonable precaution for the management of Rosepark to have fitted devices to ensure that bedroom doors were closed automatically in the event that the fire alarm sounded."
"It would have been a reasonable precaution to have fitted smoke seals to bedroom doors. Had this precaution been taken the deaths of 2 people might have been avoided"
A copy of the report may be viewed here