A NURSING home blaze that killed an 89-year-woman could have been avoided if the findings of a report published only six months earlier had been heeded, an inquest heard yesterday.

Teesside coroners court was told that a fire risk assessment report published in February 2004 identified unsatisfactory areas of the BUPA-run St David's Nursing Home, in Redcar, east Cleveland, that needed improvement.

Fire barriers in the roof space, where the fire originally took hold, were identified as damaged and in need of repair. The emergency lighting and the ceilings were also deemed unsatisfactory as were aspects of the fire alarm system.

Six months after the report was published, on August 20, 2004, fire ripped through the upper floor of the nursing home, where Dorothy Robinson, who had suffered multiple strokes and was unable to get herself out of bed. She died the next day as a result of the burns she had sustained.

Speaking at the inquest, Jacqueline Elliott, who managed the home when the fire happened, said although she was not in charge when the report was published, she was surprised that she had not been made aware of its findings when she took over in April 2004.

And when asked by James Kemp, representing the family of Mrs Robinson, "Did any remedial work take place?"

Mrs Elliott replied: "I wasn't aware that it was."

The court also heard that a report into the fire by the Health and Safety Executive, critisised the fire safety preparation of the nursing home. Amongst the findings were: Little of the training provided was specific to St Davids; Staff had little experience of mock drills; The need to conduct a roll-call was forgotten; There was no sensible estimation of the evacuation time; Some staff had not been properly trained which prevented them from discharging their responsibilities fully; Staff were confused in the early stages of the fire because they were unaware of fire detectors in the roof.

When questioned by Mr Kemp, Mrs Elliot conceded that a string of systematic blunders had taken place, but said that nursing home staff had responded well and that the fire brigade were in charge of the situation once they arrived at the scene.

The inquest continues today when members of the fire brigade will appear before the court.