Ensuring the safety of patients, staff, and visitors from the risk of fire is a critical legal and moral responsibility within the National Health Service (NHS). With complex building layouts, vulnerable occupants, and specialised medical equipment, NHS premises present unique fire safety challenges. A key component of managing this risk is the fire risk assessment, but determining who holds the ultimate responsibility for its completion can seem complex within such a large organisation.
This article clarifies the roles and legal duties for fire safety within the NHS, explaining who is responsible for ensuring a thorough and up-to-date fire risk assessment is in place for every NHS property, from large acute hospitals to local GP surgeries.
The Quick Answer
The ultimate responsibility for fire safety, including the completion of a fire risk assessment, lies with the ‘Responsible Person’ as defined by the Regulatory Reform (Fire Safety) Order 2005. In an NHS Trust, this is typically the Trust Board, with the Chief Executive holding overall accountability. However, this duty is usually delegated to competent individuals at various levels, such as facility managers, department heads, and specialist Fire Safety Advisors.
Understanding the Legal Framework
The Regulatory Reform (Fire Safety) Order 2005
The primary legislation governing fire safety in non-domestic premises in England and Wales is the Regulatory Reform (Fire Safety) Order 2005 (FSO). This law applies to all NHS workplaces and places a legal duty on the ‘Responsible Person’ to take all reasonable steps to ensure the safety of everyone on the premises. A cornerstone of this duty is to carry out a “suitable and sufficient” fire risk assessment and to act on its findings.
The Role of the ‘Responsible Person’
The FSO defines the Responsible Person as the employer or, in the case of a workplace, the person who has control of the premises. Within the complex structure of the NHS, this responsibility is tiered:
The Trust Board: As the legal entity, the NHS Trust Board is the ultimate Responsible Person.
The Chief Executive: They have overall accountability on behalf of the board for ensuring the Trust complies with all statutory duties, including fire safety.
Delegated Responsibility: In practice, the task of carrying out and managing fire risk assessments is delegated to local managers, heads of departments, or ward managers. While they carry out the task, the legal responsibility remains with the Trust.
The Fire Risk Assessment Process in the NHS
Who Conducts the Assessment?
While the Trust Board is ultimately responsible, the physical act of conducting the assessment must be carried out by a ‘Competent Person’. This is someone who has the necessary training, experience, and knowledge to identify fire hazards and evaluate the risks involved. Within the NHS, this role is often fulfilled by:
Fire Safety Advisors: Most NHS Trusts directly employ specialist Fire Safety Advisors. These professionals are tasked with providing expert advice, carrying out complex risk assessments, and ensuring the organisation’s fire safety policies are robust and compliant with guidance, such as the Health Technical Memoranda (HTM) 05 series on healthcare fire safety.
Department and Facility Managers: For their specific areas of control, local managers are often responsible for ensuring assessments are completed and reviewed. They work closely with Fire Safety Advisors to identify local hazards and implement necessary safety measures.
Key Duties and Responsibilities
The fire risk assessment process involves several key steps that the responsible and competent persons must ensure are completed:
Identifying Hazards: Systematically identifying all potential sources of ignition, fuel, and oxygen. This includes electrical equipment, flammable medical gases, and combustible waste.
Identifying People at Risk: Paying special attention to vulnerable individuals, such as patients with mobility issues, and developing Personal Emergency Evacuation Plans (PEEPs) where necessary.
Evaluating and Mitigating Risk: Assessing the likelihood of a fire starting and the potential consequences. This involves evaluating the adequacy of existing fire safety measures, such as fire alarms, escape routes, and fire-fighting equipment.
Recording, Planning, and Training: Documenting all significant findings, creating a clear emergency plan, and providing comprehensive fire safety training to all staff.
Regular Review: The assessment is not a one-off task. It must be reviewed regularly (typically annually) and updated whenever there are significant changes to the building, its use, or the people using it.
The Wider Team’s Responsibility
The Role of All NHS Staff
While specific individuals are designated with formal responsibility, fire safety is a collective effort. Under the FSO, all employees have a duty to cooperate with their employer to ensure a safe workplace. This includes:
Familiarise themselves with the findings of the fire risk assessment for their work area.
Following fire safety procedures and participating in fire drills.
Reporting any fire safety concerns, such as blocked fire exits or faulty equipment, to their line manager.
When to Seek Professional Help
Given the complexity of NHS buildings, especially large hospitals, it is standard practice to use dedicated professionals. NHS Property Services and specialist consultancies, often accredited by bodies like the Fire Protection Association (FPA), also provide support in conducting assessments. The local Fire and Rescue Service acts as the enforcing authority, guided by the National Fire Chiefs Council (NFCC), and may inspect premises to ensure they comply with the law.
Conclusion
The responsibility for completing a fire risk assessment in the NHS is layered. While the NHS Trust Board and its Chief Executive hold the ultimate legal accountability as the ‘Responsible Person’, the practical duties are delegated to a network of competent individuals, spearheaded by specialist Fire Safety Advisors and local managers. This structured approach ensures that fire risks are managed effectively at every level, from the hospital ward to the boardroom, safeguarding the well-being of millions of patients and staff every year.
