Though it said that a well-equipped building would not have changed the circumstances regarding the Mahdia dorm fire which claimed 20 lives, the Commission of Inquiry’s report into the inferno on May 21st, 2023 however slammed Chief Fire Officer Gregory Wickham and former Regional Education Officer Anesta Douglas of Potaro-Siparuni for dereliction of their duties.
The report which was handed over on Friday to President Irfaan Ali by Mahdia COI chairperson Major General (Retired) Joseph Singh and released to the press yesterday, chronicled what transpired on the night of the fire and also made recommendations and findings following a visit to communities such as Mahdia, Micobie, Chenapau, and Karisparu, all located in Region Eight (Potaro-Siparuni).
The Commission heard that on 7th February, 2023, an inspection was carried out at the Mahdia Dormitory facility by Sub Officer Ryan Scott of the Mahdia Fire Station. Following this inspection, Scott prepared a report which he addressed to Wickham and copied to Regional Education Officer (ReDO) Douglas.
From the evidence before it, the CoI said it was satisfied that the report was submitted to and personally received by both the Chief Fire Officer (CFO) and ReDO.
The CoI said that Scott’s report sets out a list of deficiencies associated with the Mahdia dormitories. It stated that for the dormitory buildings, there was a complete absence of any fire prevention system.
“Accordingly, there was no fire alarm system, no fire detection system, no exit signs and no smoke detection system. The report also highlighted that there were only three (3) fire extinguishers provided in the buildings and grills were seen on all the windows. The report went on to provide a list of twelve (12) requirements/recommendations to address fire prevention at the facility. These included: – 1. A suitable fire alarm system which can give sufficient audible warning throughout the premises must be provided. 2. All final exits (doors) must be constructed to open outwards along the line of exit travel. 3. Suitable exit signs red in colour on white background not less than 100mm in height, must be conspicuously displayed over all final exits. 4. Precise instructions with actions to be taken in the event of a fire must be prominently displayed on the walls throughout the building. 5. Suitable storage facilities (racks, shelves, cupboards, etc.) must be provided for all items. They must be constructed or situated in such a way that allows free and adequate passageway to be maintained. 6. All items stored in the building must be neatly arranged leaving a minimum clearance of at least 30cm from ceiling level and 15cm in any other direction. 7. No fuel must be stored on the premises without permission from this department. 8. A high standard of housekeeping must be maintained throughout the building at all times. 9. Grills must be removed from all windows immediately. 10. Six (6) fire extinguishers along with six (6) smoke detectors must be provided and all Fire Extinguishers must be hung on brackets with their handles 1.4m from floor level to facilitate handling by persons of any height. 11. Efforts must be made for all staff to be trained in the use and operation of firefighting equipment (fire extinguishers) and evacuation procedures. 12. Hydrants must be installed”, the CoI report said.
The CoI report added that Wickham confirmed to the Commission that at all material times, he was in receipt of the Scott report.
“The CFO told us that he was aware of all the infractions regarding the Mahdia School Dormitory which were highlighted in the report as well as the 12 recommendations/requirements listed therein.
“He told the Commission that he understood the report as requiring an urgent response and the necessity for the recommendations contained therein to be complied with”, it stated.
At the same time, the CoI said that Wickham told it that even with this understanding, his only effort to secure compliance with the recommendations was “to ensure that the REdO in that particular area was in receipt of the said report”.
The CoI said that Wickham was adamant that even though the report was addressed to him, the regular standard operating procedure to be followed was for him to ensure the document was received by the REdO. When asked about his familiarity with the REdO for Region 8, he told the CoI he could not remember the name of the officer and that he personally made no efforts to confirm whether the REdO was indeed in receipt of the report.
When asked about the report’s recommendation regarding the installation of water hydrants, Wickham agreed that this action fell outside of the jurisdiction of the REdO.
“It is important to note that the CFO in his
evidence stated that he considered the compound (with) the Mahdia Dormitories to be of high risk by virtue of the fact that a large number of children were being housed at a State-owned facility which was situated in that vicinity. He stated that the nonplacement of a water hydrant at this facility was due to the size of water mains placed by the Guyana Water Inc in the area. He informed us that setting up a fire hydrant required a 6-inch water main and that the area was only equipped with 4-inch mains which were unsuitable for the placement of a hydrant. Regarding his efforts to secure compliance, he stated that the Guyana Fire Service informed `GWI that they needed to ensure that they had the mains fixed to be the particular type that would afford us the opportunity to plant the hydrant there”.
The CoI said that by his own admission, this was the extent of his response in relation to the Scott Report.
“Again, there was no system of follow-up to see through that the request was actioned. The Commission views this as unacceptable on the part of the CFO. The CFO was asked whether by virtue of him being the most senior officer in the Guyana Fire Service, he consulted with other senior officials who had the capacity to treat with the report. To this he responded in the negative in that he made no efforts to forward the report to other senior government functionaries for their intervention. This fact was confirmed on the part of the former Permanent Secretary of the Ministry of Home Affairs, Mrs. Mae Toussant Thomas, under whose administrative jurisdiction the Guyana Fire Service fell. She told the Commission that the report was never brought to her attention by the CFO or any other member of the Guyana Fire Service. The Permanent Secretary Thomas was keen to note that the Ministry of Home Affairs’ operational procedures have always allowed for responses to emergency situations even where it was not budgeted for or predicted”, the CoI said.
The Commission said the CFO’s explanation that the standard operating procedure only required him to ensure the ReDO was furnished with the report, was essentially passing off to the REdO, the responsibility of ensuring that the emergency recommendations in the report were brought to life.
“We also find it regrettable that in all circumstances and even with all his experience as the most senior fire officer in this country, the CFO did not see the need, nor did he take the initiative, to communicate to the Permanent Secretary of his Ministry, the said emergency recommendations. It is expected that the head of the fire service of any country, having reports such as these, would go beyond the bounds of duty and service to ensure compliance therewith. This we feel, in all circumstances, was lacking from the Chief Fire Officer”, the Inquiry’s report read.
The Commission was gravely concerned that at the time of the fire, many of the urgent recommendations in the reports submitted to Wickham were not actioned.
The report stated, “This concern was elevated by the fact that the reports identified the absence or unworthiness of several tools of trade which, to our minds, are essentials for executing the function of firefighting in this country”.
According to the CoI report, the CFO was confronted with the reality of the Mahdia Station and the issues encountered in its response to the events of 21st May, 2023. To the unavailability of essential items during the response such as breathing apparatus sets and breaking-in tools such as sledgehammers, disc cutters and belt croppers inter alia, the CFO explained that the Fire Service was unable to provide such supply “because, through our budgetary allocation, we were not able to acquire any at the particular time”.
The Commission stated that it rejected the CFO’s explanation of budgetary constraints as a justification for Mahdia Fire Station not being supplied with essential tools of trade to effectively carry out their functions on the night in question.
“As we learnt from the former Permanent Secretary of the Ministry of Home Affairs (Mae Toussaint Thomas) the said ministry has systems in place to respond to any emergency request. An emergency request for the supply of essential tools of trade made at the level of the CFO would not have been denied”, the CoI report stated.
Wickham, according to the CoI report, relied on the excuse that the effluxion of time from the tender’s last maintenance caused the mechanical issues to ensue, but this excuse found little favour with the Commission since it was the CFO who was specifically informed of the issues with the tender, which he admitted was an aged appliance. The CFO therefore should have ensured systems were put in place either for a new tender to be provided, or there was regular maintenance and repair of the tender.
The Inquiry also expressed dissatisfaction at the fact that up to the time of the fire, there was no effective system of contacting the Mahdia Fire Station.
“Sub-Officer Ryan Scott told us that members of the town had to contact his mobile phone. The guard who was on duty at the night of the fire did not know Sub-Officer Scott’s number and so could not call him”, the CoI said.
Dereliction by the REdO
According to the CoI, the conduct of the REdO was not far from that of the CFO.
“If we are to accept the timeline of events as was suggested by Ms Douglas, in that she received the report from Mr Scott on the afternoon of the 7th February 2023, and then unconfirmed information about her reassignment in the afternoon of the 8th February 2023, it is certain nothing prevented her from taking some form of action on the report, or at a bare minimum, bringing it to the attention of some other authority”, the commission stated.
It rejected the excuses proffered by Douglas to justify her inaction and found them to be spurious and vexatious.
The inquiry is of the firm view that she gave no attention and showed complete disregard for the report.
The Commission said that if prudent action was taken by the REdO, there was more than sufficient time for effective fire prevention systems to have been put in place “in the interest of life and fire safety” as was concluded by Sub-Officer Scott in his report.
“We, in all the circumstances, consider the actions and inactions of the REdO to be careless, negligent, a complete dereliction of duties and falling far below the standard of officers serving the Education system of this country”.
Unpreparedness and insufficiency of resources
The Commission in its report considered that the duty officers and auxiliary firefighters provided the best possible response to the fire based on the circumstances they were confronted with at the Mahdia Fire Station on the evening of 21st May 2023.
However, the inquiry said that it cannot negate the fact that the Mahdia Fire Station, due to poor leadership at the highest level of the Guyana Fire Service, was unequipped and ill-prepared to provide an effective response to the fire at the dormitory.
It is adamant that the non-provision of essential tools of trade for effective firefighting, especially where there are systems in place to access resources, is unacceptable and inexcusable.
“We are convinced that the state of affairs at Mahfia Fire Station was the direct result of poor leadership of the Fire Service and lack of initiative”.
The Commission also noted that Mahdia Secondary School dormitory was in a state of unpreparedness to deal with the fire.
Though there was a single fire extinguisher in the building, the state of the dorm fell way below the standard of that which was contemplated by Ryan Scott’s report, the inquiry flagged.
Social, Societal and Cultural Issues
The CoI report stated that based on its findings there was substantial tension between the norms, rules, and regulations of dorm life with life in the villages.
The relocation of students away from their communities, compounded with the absence of any permanent welfare officer and or guidance counsellor attached to the dormitory, aggravated a situation which was already challenging for both the house supervisor and the students.
The inquiry found that the House Supervisors were not formally trained for their tasks, and certainly not trained to provide counselling and psychological support to the students who were at a vulnerable stage of their development and in dire need of this type of support.
Further, in the case of the female dormitory, there were too many students under the care of the House Supervisor to allow her to effectively provide proper care and supervision.
“Our finding is that the students required greater care, supervision, and support than that which was provided”.
“We find that the House Supervisors were untrained and unskilled in fire emergency evacuation techniques and had absolutely no plan to manage emergencies. There were no emergency and evacuation procedures in place, or at the very basic minimum, there was no one else in the compound with keys to open the doors in the event of an emergency or even the keys to the doors being kept on a separate bunch for easy access. There was simply no emergency plan in place”, the CoI said.
