Final Report Issued On Fatal West Chester Nursing Home Fire

WEST CHESTER PA — The investigation into the tragic 2017 fire at Barclay Senior Friends Center in West Chester has been completed, and the cause of the blaze which claimed four lives and displaced 152 residents and staff into the bitter cold night remains unknown.

Officials did confirm and clarify what attorneys of the fire's victims have been saying since the start: the sprinklers are part of the equation.

The main sprinkler valve was found in the off position when investigators arrived at the scene, the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) said in their final report. It's not clear how long it was turned off for, who turned it off, or why. But investigators believe it was off during the blaze.

There is no indication of arson, officials said.

The final report also addressed other factors which excaberated the situation. There were high winds on the night in question, and the flames spread quickly across the flammable vinyl exterior of the building, officials said.

Furthermore, because there were no exterior sprinklers — something not required by code — the fire was able to rapidly spread to the roof and other parts of the Center.

The blaze began just before 11 p.m. on Nov. 16, 2017 in the rear garden room on the outdoor patio, underneath the Woolman building overhang, officials said.

The fire rapidly became an inferno, as five alarms were quickly raised. More than 400 first responders joined neighbors in the area in rushing into the building to rescue the residents, many of whom were in wheelchairs and had physical and mental issues.

The final report indicated that smoke and fire alarms "acted as designed," with strobes and sirens, and that the smoke detectors cuased the fire doors to shut as they should.

Four were killed: 92-year-old Delores G. Parker and 88-year-old Thomas F. Parker, who were husband and wife. Two other women, Mildred E. Gadde, Theresa J. Malloy, were also confirmed dead. Their cause of death was listed as smoke inhalation.

Robert J. Mongeluzzi, an attorney for the family of Malloy, has previously siad that Barclay "failed in its obligation to protect this wonderful woman."

Chester County District Attorney Tom Hogan said the 14-month inquiry, made by a joint task force from the ATF and the Chester County Fire Marshal's Office, "exhausted every avenue of investigation."

The ATF's National Response Team was activated for the incident, a group which i ncludes fire investigators, explosives specialists, fire protection engineers, chemists, forensic mappers, and other experts. More than 300 interviews were conducted, the fire scene was re-examined, and, later, re-created, and extensive tests were done at an ATF lab in Beltsville, Maryland.

In their final report, officials reiterated that things could have been much worse, were it not for the heroism of local neighbors and first responders working together to bring residents and staff to safety.

"Because of the extensive efforts of the West Chester Fire Department, many lives were saved that night," Chester County Fire Marshal John Weer said in a statement. "With the intensity of this fire prior to notification, many heroic efforts were carried out. Heavy hearts are with these men and women for the losses of life and our sincere thoughts are with their families."

See related:

• Sprinklers To Blame In Catastrophic West Chester Fire: Attorneys
• Remains Of Final 2 Victims Of Fire Found In Rubble In West Chester
• 4 Unaccounted For After Fire At West Chester Senior Home
• Community Rallies After Devastating West Chester Fire
• Massive Fire Destroys Pennsylvania Senior Living Facility: Video

Photo credit: Pete Bannan/Daily Local News via AP; WPVI-TV via AP