1978 — Dec 9, Ellisville State School/mental hospital women’s dorm fire, Ellisville, MS– 15

–15 Bell. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, 73/4, July 1979, p. 68.
–15 Jones. “1978 Multiple-Death Fires: Smoking Materials Lead…” Fire Journal, 73/4, July 1969, p8.
–15 National Fire Protection Association. Key Dates in Fire History. 1996.
–15 National Fire Protection Association. The 1984 Fire Almanac. 1983, p. 137.
–15 National Fire Sprinkler Association. F.Y.I. 1999, p. 6.
–15 NYT. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p.26.
–15 Paris News, TX. “15 Women Die in Dormitory Blaze,” December 10, 1978.

Narrative Information

Bell: “On December 9, 1978, an early morning fire originating in a clothing storage room in a residential custodial-care dormitory at a state mental hospital outside Ellisville, Mississippi, killed 15 of the 63 residents and hospitalized 16 others. Smoke spreading from the storage room simultaneously filled two wards on the top floor of the two-story, fire-resistive building. Primary factors resulting in the fatalities were the lack of compartmentation and automatic sprinkler protection of the storage room, lack of subdivision of the facility by a smokestop partition, lack of an automatic detection and alarm system, and lack of automatic alarm transmission to the fire department. Additional factors contributing to the loss of life included the lack of illumination during the evacuation of residents, limited fire service resources, and the mental and physical handicaps of the residents.

“Magnolia Dormitory, the building in which the fire occurred, was one of approximately 20 residential buildings on the hundred-acre campus of the Ellisville State School, located outside Ellisville, Mississippi. The building, classified according to NFPA 101, the Life Safety Code, as a residential custodial facility, was constructed as a two-story structure in 1962 and operated as a single housing unit. An addition to the ground floor that was built in 1975 allowed each floor to operate as a separate dormitory unit….

“The physical and ambulatory capabilities of the residents varied. Wheelchairs and walkers indicated that a number of residents had difficulty in movement. These residents would have requited assistance in descending the fire escape stairs….

“On the evening before the fire, the residential custodial care facility housed 63 moderately to severely mentally retarded female residents on the first floor ranging in age from 40 to 68. The ground floor contained another housing unit designated as the ‘Swinging 60’s,’ which housed a similar number of both male and female, moderately to severely mentally retarded residents segregated in male and female sleeping wards….

“Magnolia Dormitory was one of three residential buildings on the Ellisville School campus that had been designated for upgrading to state standards for intermediate care and mentally retarded care facilities. In addition, it had recently been further identified for upgrading to skilled nursing facility standards using the requirements of NFPA 101 – 1973 (the Life Safety Code) for new health care occupancies…Funding had been appropriated by the State Legislature at its last session to cover the cost of these renovations. The preliminary plans had been prepared by an architect retained by the state….

“A structural survey completed by the Mississippi State Building Commission had identified the building’s fire protection deficiencies as part of its overall building survey…It the area of Safety Standards…the building received 0 (zero) out of a possible 8 points. The building had an overall rating of Satisfactory-Adequate, based on this rating system.

“The Fire

“On December 9, 1978, three of the six night attendants normally assigned to Magnolia Dormitory were on duty for the night shift. After taking a break, all three attendants were in the Ward 1 area, folding and sorting clothes in two separate clothing storage rooms. A resident of Ward 1 asked one of the attendants for permission to get a drink of water. The resident then walked out of the ward and went to the Day Room. At the same moment, an attendant in Ward 1 asked the other attendant if she smelled something. The resident immediately returned from the Day Room, saying, ‘There’s smoke in the Playroom (Day Room).’ The attendant called to the other two attendants, and told them about the reported smoke. All three attendants ran into the Day Room and found the far (north) end filling with smoke. The time was approximately 1:45 am.

“The first attendant went to the nearby office and telephoned security personnel. She informed the guard who answered that there was a fire in Magnolia Dormitory and that they needed help. The guard did not call the Fire Department; instead, he went to the Magnolia Dormitory, after going to the switchboard operator’s office to give the alarm. The attendant then returned to Ward 1, pulling the double corridor doors closed behind her. (The continued spread of smoke into Ward 1, however, indicated that they were not closed. During a later inspection, it was found that if the doors were not fully closed, with both leaves secured, one leaf had a tendency to swing back into the open position and come to rest parallel to the wall.)

“The attendant immediately went to an area in Ward 1 in which three residents confined to wheelchairs were sleeping, awakened them, and told them to get into their wheelchairs. She then continued down the right-hand row of beds, rousing the residents and telling them to get out of bed and follow her. As the passed the fifth set of beds, she reported later, the lights flickered and went out. (The lights referred to were lights in the storage closed adjoining the ward, not the main ward lights or lights on the emergency lighting circuit.) She then made her way to the rear of the ward to the exit door, opened it, and stayed at the door calling for the residents to come to her. She stayed at this location directing residents to come to her until additional on-duty staff, security personnel, and off-duty staff began to arrive to help her. With this assistance, they began to carry the wheelchair-confined residents down the fire escape stairs and guided the ambulatory residents into the ward on the ground-level floor below.

“Meanwhile, the two remaining attendants had entered the Day Room and found it filling with smoke at the far (north) end. They ran through the Day Room to the north end. They looked down the corridor leading toward Ward 2 and noted that smoke was coming from the clothes storage room that adjoined the corridor ‘as if blown by a fan.’

“Seeing that they could not make it down the corridor to Ward 2 past the door of the clothing storage room, the attendants ran down the open stairway into the women’s ward located in the ‘Swinging 60’s’ area on the ground floor. They went out the exit door to grade level and up the fire escape to the exit door leading to Ward 2. Pulling the door open, they were met by a rush of smoke. They called into Ward 2 for the residents to ‘come to Momma.’ Seeing that Ward 2 was both dark and smoky, both attendants ran back down the stairs. Reentering the ‘Swinging 60’s’ area, they met the female attendant in the female ward, told her that there was fire upstairs, and advised her to get the residents in her ward out of the building.

“One of the attendants then found a flashlight and returned to the exit door of Ward 2, shining it into the ward while calling for the residents to come to the light. The other attendant went to the office in the ‘Swinging 60’s’ area and called the night switchboard operator; she informed her of the fire in Magnolia Dormitory, and said that they could not see because the lights were out. The attendant asked that flashlights be brought. With the flashlights, she was able to evacuate eight to ten residents prior to the arrival of fire fighters.

As the night switchboard operator was taking this call, the security guard came in and told the assistant operator to go to the guard station at the main entrance of the hospital grounds and man it while he went to the Magnolia Dormitory.

“At approximately 1:50 am, about five minutes after discovery of the fire, the night switchboard operator called the Ellisville Fire Department to report the fire. She then called the School’s Director and other staff members on the call list, starting with local Ellisville numbers. Some of the administrative staff members lived in housing directly across Highway 11 from Magnolia Dormitory. This situation was a significant factor in the evacuation and/or rescue of a large number of the Dormitory’s residents.

“The two attendants on the ground floor awakened the residents of the two ground-floor wards, then started moving them to the lobby area to await further evacuation. The lights on the ground floor were turned on and remained on throughout the fire. Some of the ground-floor residents had to be physically carried out to the lobby area when they refused to leave the ward or proceeded to follow their normal pattern of activity when they first awakened in the morning (i.e., such as making their beds). The attendants also stated that they had difficulty preventing patients from returning to the ward unless an attendant was in view. They residents, they said, would follow the orders given by attendants they knew.

“…Efforts of the attendants to enter the ward [1] were prevented by heavy black smoke. There was no outside illumination, which made it difficult to move in the nearly total darkness.

“The first engine from the Ellisville Fire Department arrived at approximately 2:05 am. The Assistant Chief, who was driving, parked the apparatus on the north side of the building. After placing the pump in gear, he heard the attendant on the outside fire escape call, stating that she ‘needed help; there are people in there.’ As he climbed the exit stairs, the attendant again said that she had 28 people inside the building. He donned self-contained breathing apparatus and was joined by a fire fighter who was similarly equipped. He entered Ward 2, located five residents, whom he brought to the exit doorway, and then ran out of air.

“Off-duty administrative personnel and staff members who lived across the highway from the Magnolia Dormitory were arriving to help evacuate patients and care for those who had been evacuated. Additional night staff members from other residential buildings also arrived, either in response to a call from the School’s switchboard operator or because they were attracted by the fire noise and activity.

“At approximately 2:15 am, the telephone operator in the Security Building was requested to place a call to the Fire Department in Laurel, 5½ miles north of Ellisville. Two engines were dispatched at 2:15 am with two men each, and the Laurel Chief of the Department responded from his home. These fire units arrived between 2:25 and 2:30 am. Laurel fire fighters immediately donned breathing apparatus and began search-and-rescue operations in Ward 2 and then in Ward 1. These sweeps located the first reported fatalities at approximately 2:45 am. Search-and-rescue operations continued until 3:15 am, when the last victim was removed from Ward 2….

“The lack of sufficient refill air for breathing apparatus and the small number of breathing apparatus units available made it difficult for Fire Department personnel to perform both fire-fighting and search-and-rescue activities….

“Bodies of 14 victims were found at the scene. The fifteenth victim reportedly died after being transported to the Infirmary.

“Autopsies were performed on two of the 15 fatalities, one from each ward. The cause of death for each of these victims was listed as carbon monoxide inhalation…neither victim was burned. However, one other victim, a resident of Ward 2 whose bed was closest to the fire, was burned….

“The double-leaf doors in each ward corridor had no self-closing devices and required manual closing. Doors were installed that way on the assumption that when detection occurs, the alarm is given and appropriate action is taken to close the corridor doors. In this fire, the required actions outlived above did not occur.

“Neither an approved automatic smoke detection system nor a manually operated fire alarm system had been installed in Magnolia Dormitory. Since all three of the duty attendants were in the area of Ward 1, detection of the fire was delayed until the fire had reached an advanced stage. Further delays were encountered in notifying the Fire Department. Early detection could have provided time to confine the fire, give the alarm, and evacuate residents while ambient conditions were less hostile….

“Heat and flame issuing from the open doorway of the clothing storage room impinged directly on the emergency lighting conduit, causing the insulation to melt and a short circuit to occur. The short tripped the circuit breaker in the emergency circuit-breaker panel located in the mechanical room, leaving the north end of the building without emergency lighting.

“However, in this fire, the emergency lighting circuits on the first floor were not used. The dual-function lighting circuits were switch in the ‘off’ position in both wards. The attendant entering Ward 1 to evacuate the residents did not turn the lights on. In Ward 2, the switch could not be reached by the attendants, and the circuit shorted out soon after discovery of the fire….

“The School’s emergency procedures required that the switchboard operator be notified of a fire. The operator’s initial call was required to be placed to the Ellisville Fire Department. The notification procedures then provided that subsequent calls be placed according to the standing staff call list. In this fire, the initial call reporting the fire was made to the security guard’s office, rather than directly to the switchboard operator. This resulted in a delayed alarm, since the security guard then left his office to go to the switchboard operator’s office in a nearby building. By the time he had reached that office, the second call was being received. The operator then notified the Ellisville Fire Department at approximately 1:50 am, and then placed calls to school staff members.

“In terms of numbers alone, the three (first-floor) on-duty attendants could not be expected to perform an orderly and expedient evacuation of both dormitory areas in time to prevent casualties. The mentally handicapped condition of the residents required a constant face-to-face contact in order to obtain the proper movement. Prior training, established behavior patterns, and limited ability to perceive the danger and develop an appropriate response added to the evacuation problem.

“Although hampered by continued smoke and heat conditions and lack of lighting, on-duty and off-duty staff members and responding fire fighters were ale to evacuate 48 of the 63 residents of both wards; 16 of the 48 residents evacuated were injured. Key factors in the evacuation were the availability of staff in nearby homes and the fact that the exterior doors to both wards were unlocked and accessible.” (Bell. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, Vol. 73, No. 4, July 1979, p. 68-76.)

Jones: “Institutional
“Institution for the Mentally Retarded, Ellisville, Mississippi…
“On December 9, 1978, a fire that originated in a clothing storage room of this residential custodial care dormitory killed 15 residents. The primary factors leading to the loss of life were reported to be: lack of compartmentation and lack of automatic sprinkler protection in the room of origin, lack of subdivision of the facility by smokestop partitions, lack of an automatic detection and alarm system, and the lack of automatic alarm transmission to the Fire Department.” (Jones. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, p. 38.)

Newspapers

Dec 9, NYT: “Ellisville, Miss., Dec. 9 — Fifteen women patients died after they were overcome by smoke and heat early today in a dormitory at the Ellisville State School for the mentally retarded. Gov. Cliff Finch called the fire the ‘worst tragedy to ever hit our state.’ Calling for an investigation ‘from top to bottom,’ Governor Finch was critical of the institution’s staff for not alerting the patients in time for them to escape.

“The dead, who were in a second‐floor sleeping area for 69 middle‐aged and elderly female patients, were overcome by smoke from a fire in a clothes and linen closet at the end of the sleeping area, the authorities said. Sixteen other patients were taken to Jones County General Hospital, where three were reported to be in critical condition.

“Dr. Paul Cotten, director of the institution, defended the actions of his staff. He said three attendants were on duty on the dormitory floor and a total of six were in the building at the time of the fire. The first floor of the building is used for ceramics and therapy training and the upper floor is used as a sleeping area, which is divided into three wards.

“Fire officials, who arrived at the scene soon after receiving the alarm at about A.M., said most of the dead were found in their beds but that several were on the floor under their beds.

“ ‘There were no smoke detectors in the building as far as we know,’ said Capt. Donald Rogers of the Laurel Fire Department, which was called to assist the volunteer Ellisville Fire Department. ‘There was no problem bringing the fire under control,’ Capt. Rogers said. ‘The main problem was getting the patients out of the smoke‐filled and darkened dormitory.’

“Governor Finch had flown here this morning from the Democratic midterm convention in Memphis to inspect the site, and he later returned to Memphis. He charged that the staff was ‘not in close enough proximity’ at the time of the fire to properly assist the patients.

“The State Fire Marshall, James Crutcher, arrived at the scene this morning to conduct a preliminary investigation.” (New York Times. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p. 26.)

Dec 10, AP/Paris News, TX: “Ellisville, Miss. (AP) — A smoldering fire in a clothing room sent a blanket of smoke through a dormitory of a center for the mentally retarded early Saturday, killing 15 women patients and injuring 16 others, authorities said. The victims — all women 40 years and older and classified as moderately to severely retarded — died of smoke inhalation in the fire at the Ellisville State School in this town 75 miles southeast of Jackson. The center served as both a school and hospital for 129 patients. ‘Some of them were in their beds and others were on the floors,’ said Ellisville Fire Chief Frank Williams. ‘They were trying to get out but they just didn’t make it.’

“The fire broke out during the early morning in a room for storing clean clothing adjacent to two second-floor wards where 66 women patients were sleeping. The 63 men and women who occupied the ground floor escaped without injury. The state fire marshal’s office said it appeared the fire began in a closet in the room.

”Hospital staff, firefighters and police officers dashed into the dense smoke to evacuate the patients. ‘It was thick smoke from the floor to the ceiling and it was superheated,’ said Van Carter, a dormitory supervisor. ‘They kept going back in and helping people out. Nobody panicked.’ ‘The difficulty was we couldn’t get into parts of the building because of the smoke,’ said a nurse who helped pull coughing patients from the building. ‘It was so thick. I’d get in a few feet and get dizzy and fall to my knees.’

”Dr. Paul Cotten, the school’s director, said most of the damage was confined to the clothing room, but that there was ‘a tremendous amount of smoke.’ The room held the electrical panel for the upper floor. Cotten said that there were no fire detection devices in the center and that it appeared the fire was unnoticed until one of three cottage parents assigned to the second floor smelled smoke. He said patients in the upper level, women either moderately or severely mentally retarded, were helped down stairs to safety. ‘When it started, the power went off,’ said a hospital staff member who asked not to be identified. ‘They were fighting to get out (in the dark) .. It’s bad enough when we have fire drills in the day.’

”Officials said 14 of the women apparently died either before or during the evacuation, and another died later at the center’s infirmary.” (Paris News, TX. “15 Women Die in Dormitory Blaze,” December 10, 1978.)

Sources

Bell, James R.. “Fifteen Residents Die in Mental Hospital Fire.” Fire Journal, Vol. 73, No. 4, July 1979, pp. 68-76.

Jones. “1978 Multiple-Death Fires: Smoking Materials Lead Ignition Sources.” Fire Journal, Vol. 73, No. 4, July 1969, pp. 33-40.

National Fire Protection Association. Key Dates in Fire History. 1996. Accessed 2010 at: http://www.nfpa.org/itemDetail.asp?categoryID=1352&itemID=30955&URL=Research%20&%20Reports/Fire%20statistics/Key%20dates%20in%20fire%20history&cookie%5Ftest=1

National Fire Protection Association. The 1984 Fire Almanac. Quincy, MA: NFPA, 1983.

National Fire Sprinkler Association, Inc. F.Y.I. – Fire Sprinkler Facts. Patterson, NY: NFSA, November 1999, 8 pages. Accessed at: http://www.firemarshals.org/data/File/docs/College%20Dorm/Administrators/F1%20-%20FIRE%20SPRINKLER%20FACTS.pdf

New York Times. “15 Women Die in Dormitory Fire at School for Mentally Retarded.” 12-10-1978, p. 26. Accessed 6-15-2021 at: https://www.nytimes.com/1978/12/10/archives/15-women-die-in-dormitory-fire-at-school-for-mentally-retarded-most.html

Paris News, TX. “15 Women Die in Dormitory Blaze.” 12-10-1978. Accessed at: http://www.newspaperarchive.com/PdfViewerTags.aspx?img=113060608&firstvisit=true&src=search&currentResult=0