Multiple defects led to a fire that killed two guests at the Cameron House Hotel.
A Fatal Accident Inquiry into the circumstances surrounding the horrific blaze at the top Loch Lomond hotel made six recommendations after Simon Midgely, 32, and Richard Dyson, 38, died in the tragedy.
The 122-page determination was published today after a hearing at Paisley Sheriff Court, with Sheriff Thomas McCartney ruling that precautions could have realistically been taken that would have avoided the couple's death.
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More than 200 guests ran for their lives when a fire broke out after night porter Christopher O'Malley disposed of ash in a cupboard at the five-star hotel in the early hours of December 18, 2017.
Recommendations include "robust procedures" for the removal of hot ash from open fires and that "clear and robust arrangements" are in place for promptly ensuring all persons are accounted for.
Sheriff McCartney also said the hotel all staff, in particular night shift staff, have experience with evacuation drills.
He also made two recommendations for the Scottish Government. These are that sprinkler systems should be considered in future conversions of historic buildings to be used as hotels.
Ministers should also create an expert working group to explore the special risks that existing hotels and similar premises may pose, he said.
The final recommendation is that Scottish Fire and Rescue Service should reduce the time period between a fire safety audit inspection and the issue of a written outcome report.
Sheriff McCartney also said there were "a number of defects in systems of working which contributed to the accident resulting in the deaths".
These included the full ash bins in the service area, "careless" disposal of ash in "unsuitable receptacles and areas", the lack of a coherent system to empty ash bins in the service area when they became full and the "presence of combustibles" within the concierge cupboard, where the fire started.
In his summary, Sheriff McCartney said: "The immediate cause of the fatal fire at the hotel was the placing of hot ash within the concierge cupboard at the reception area of the hotel, which allowed a fire to develop within said cupboard and then spread to other parts of the hotel, exposing both deceased to the effects of smoke and fire gases.
"Precautions which could reasonably have been taken which might realistically have resulted in the deaths or the accident resulting in the deaths being avoided have been identified.
"There were a number of defects in systems of working which contributed to the accident resulting in the deaths and also a number of other facts which are relevant to the circumstances of the deaths.
"Arising from the inquiry are a number of recommendations as set out in this determination.
"The Crown and the participants in their submissions offered condolences to the families of Mr Midgley and Mr Dyson. I wish to conclude by expressing the deepest sympathies and condolences of the court to both families."
In January 2021, hotel operator Cameron House Resort (Loch Lomond) Ltd was fined £500,000 and porter Christopher O'Malley was given a community payback order over the fire.
The hotel firm admitted failing to take the necessary fire safety measures to ensure the safety of its guests and employees between January 14 2016 and December 18, 2017.
The company admitted two charges of breaching the Fire (Scotland) Act 2005.
O'Malley admitted breaching sections of health and safety laws which relate to the obligation of an employee to take reasonable care for the health and safety of people affected by their acts or omissions at work.
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