NFPA Journal - January/February 2020 - 80

Looking Back

FIRE INCIDENTS AND
OTHER NOTABLE EVENTS
FROM SAFETY HISTORY

BEHIND
BARS

THE ST. ELIZABETH'S MERCY
HOSPITAL FIRE OF 1950-
DAVENPORT, IOWA
By Matthew Foley
n January 7, 1950, 62 patients
were locked in St. Elizabeth's,
the women's psychiatric ward of
Mercy Hospital in Davenport,
Iowa. The two-story building
was nearly 80 years old and was the oldest of
Mercy's four buildings. There were no sprinkler or fire alarm systems, and the windows of
patient rooms were covered with metal bars.
The patients were attended by a nurse and
her aide, and included a woman who had been
locked in isolation. This was an abnormal treatment for her; enraged, she used a contraband
cigarette lighter to ignite a curtain in her room.
No one noticed the flames until it was too late.
Around 2 a.m., an employee in an adjacent
building saw the flames spilling from St. Elizabeth's and told his coworkers to call the fire
department. He raced to the burning building
to investigate but was turned away by the
growing fire. Firefighters arrived on the west
side of the building to find flames erupting
from some of the windows; behind other windows they could see silhouettes of the women
pressed against them, behind the bars, backlit
by the glow of the raging fire.
The ward had no evacuation plan, and locked
doors prevented movement inside the building.
Outside, many rescue attempts were thwarted
by the barred windows-firefighters had to chop
the bars out of each wooden window frame to
reach patients trapped in their rooms. "They
weren't screaming and didn't seem excited
much. They just looked bewildered," recounted

80 | NFPA JOURNAL * J A N U A R Y / F E B R U A R Y 2 0 2 0

THE NFPA LIBRARY AND ARCHIVE holds a rich collection of books, reports, and photographs that
document important moments in fire history. To provide better electronic access for researchers and
to preserve our unique archival holdings, work has begun to digitize the files of the Fire Record Department, the original NFPA department responsible for collecting and analyzing information and compiling
statistics about key fires and other events. The incidents featured in "Looking Back" are drawn from this
collection and will eventually be part of NFPA's online archive. For information, visit nfpa.org/library.

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one patrolman who assisted with the rescues. "Sort of like creatures who had
something new happening to them and didn't know just what to do."
The fire killed 40 of the ward's patients, along with the on-duty nurse.
Responders rescued 22 patients, and the nurse's aide fled after being wakened by screams. "I didn't relish the prospect of jumping from the third
floor," the aide explained in a newspaper account of the fire. "If I hadn't
gone when I did, I might have been trapped like the others."
The fire department would later discover that the west side of the
building was actually the more manageable side. A light wind had carried
flames across the hallway, creating an inferno on the east side that would
leave no survivors. "There was very little screaming in the part of the
building where I was, but I could hear terrible, terrible yells from other
parts of the building," one patrolman noted.
An investigation revealed critical deficiencies that exacerbated the fire.
The fire department had recommended a sprinkler system for the facility
for more than 25 years, but it had never been installed. The absence of fire
protection systems and an evacuation plan, along with locked egress doors
and barred windows, led to a reevaluation of the fire hazards in health care
occupancies that had been neglected for most of the era.

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NFPA Journal - January/February 2020

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