The New York Civil Liberties Union today released an incident report it received from New York State’s Office of Mental Retardation and Developmental Disabilities in which the office questions the veracity of reports filed with it purporting to document fire drills at a Hamilton County group home where four residents died in a March fire.

Employees at the group home were to have conducted a series of fire drills at all hours of the day and night and all staffing levels to ensure a quick and safe evacuation of the home. But records found after the fire “call into question the veracity of the drills,” according to an incident report created by New York State’s Office of Mental Retardation and Developmental Disabilities, the state agency tasked with ensuring the safety of residents at homes such as the Riverview residential center in Wells where four people died in a March 21 fire.

The fire drill records were provided to the NYCLU as state investigators were concluding a report blaming the deadly fire on “human action.”

Five of the nine residents of the Wells group home were plaintiffs in the Willowbrook case, the NYCLU’s 1972 landmark class action lawsuit brought on behalf of 6,000 people with developmental disabilities who resided at the notorious Willowbrook State School on Staten Island. As a result of that lawsuit, the Willowbrook Class members were released from the school and placed in group homes statewide.

A court order requires New York State to provide services for and protect all members of the Willowbrook Class. But two former Willowbrook residents were killed in the March 21 blaze and another was severely injured and flown by med flight helicopter to the hospital. Two other residents of the home also died.

The fire drill records were supposed to have documented drills that showed residents at the home could be evacuated in eight or less minutes under any circumstance. But the residents of the home had severe developmental and physical disabilities, and would not have been able to evacuate themselves in case of a fire.

“The state needs to immediately find out why these fire drill reports failed to raise any red flags,” said Donna Lieberman, NYCLU executive director. “How is it possible that these nine severely disabled people would be able to be evacuated in the middle of the night by only two people? Why didn’t this claim ring a giant alarm?”

Late Wednesday, the Department of State’s Office of Fire Prevention and Control released its 111-page report on the fire. It found four code violations, and flagged 22 “items for review,” issues the Office of Fire Prevention believes warrant further discussion as a matter of public policy.

The report by the state’s Office of Fire Prevention tells a harrowing story of the two staff members working who appeared to have no idea how to get the residents out. One stopped to answer the phone when the fire alarm monitoring company called and neither tried to use any of the closer side exits. One sprayed a fire extinguisher at a closed door. The fire was on the other side.

The report also raises questions about the building’s materials. Though the home was less than a year old, the fire spread very quickly from the home’s enclosed back porch through the attic. The report suggests that had there been a better sprinkler system or had stronger materials been used, there may have been more time to evacuate the residents.

“It appears that there was a cascading series of poor judgments and insufficient oversight, from the staff on the ground on up,” said Beth Haroules, the NYCLU’s lead counsel on the Willowbrook case.

A criminal investigation being conducted by the State Police and the Hamilton County District Attorney is pending. That investigation will also determine the fire’s origin.

In 1972, the NYCLU filed a historic civil rights lawsuit to challenge the inhumane institutional conditions suffered by the residents of the infamous Willowbrook State School. These rights include protection from harm, a safe, clean and appropriate physical environment, high quality community residential and treatment services in the least restrictive setting and high quality case management and advocacy services.

The NYCLU has already called for the state attorney general to investigate the fire as it is the attorney general’s obligation to ensure that New York is in compliance with the Willowbrook court order.

“We are looking at every legal option available to protect the thousands of Willowbrook Class members still in New York,” Lieberman said. “We must know everything that happened that contributed to this tragedy, and we must ensure that nothing like this ever happens again.”

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