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appeared to be in order. At 9.20 p.m. Nurse Blythe stated she came back to brick building to resume duty. On her way she passed through Ward 5 on the ground floor. She looked into the single rooms on the ground floor. She saw nobody about, and no signs of fire. Nurse Ward on being relieved went to Ward 1, passing outside the east side of Ward 5. Between 9.30 p.m. and 9.40 p.m. Mrs. Blackmore, clerk in the office at Mental Hospital, accompanied by Miss Rowlands, typiste, both of whom resided at the nurses' home, passed Ward 5 on their way from Seacliff township to the nurses' home. They both agree that they heard and saw nothing unusual about the ward. Mrs. Blackmore was of the opinion it was not more than ten minutes from the time she passed the building that she heard the fire-alarm. / The alarm of fire was given, so far as we can determine, between: 9.50 and 9.55 p.m. by attendant Henderson, who was unable to give exact time. The time alarm sounded was not electrically recorded. During that evening a very high southerly wind was blowing. It may be noted that this witness had passed Ward 5 some time after 9 p.m. and saw no sign of fire. He saw the fire from residential block known as " The Ranch," which is about 70 yards south-west of Ward 5 on the hill. He ran down to sound the alaim situate outside the Assistant Medical Officer's quarters, which is south of and not far from the brick building (part of Ward 2). He then went at once to the fire-station and took the reel and hoses out and ran them along to the hydrant at the corner between Ward 5 and the brick building. In a short time Mr. Driscoll, Captain of the Fire Brigade, arrived on the scene with other men and took charge. When lie arrived building was a mass of flames. He described how he rescued one patient in east side of ward by ripping grating off and taking her out through the window, which was open. On his arrival he stated there was absolutely no chance of saving the building. Dr. Brown, the Medical Superintendent, received alarm at 9.55 p.m. at his residence. He hurried to scene and found Ward 5 a mass of flames. He considered it impossible then to enter the building. "f-Two patients were saved from the building —one on the upstairs and one on ground floor. Both were privileged patients whose windows were not shuttered. There was no evidence of any unusual noise by the patients in Ward 5 prior to the discovery of the fire./. From the foregoing it is clear the fire was when first discovered of such magnitude and its spread so rapid that we have found it impossible to determine in which part of the building it originated. The opinion we have formed is that it originated inside the building, probably on the first floor towards the northern end. The building was completely burned to the ground, and no expert was able to assist us in definitely stating where the fire originated. In dealing with the possible—we cannot say probable—cause of the fire we come into the realm of conjecture. The possible causes placed before us were — (i) Sparking from electrical equipment or from defective radio: (ii) Action of rats: (iii) Action of patients—smoking or secreting matches: (iv) Sparks from the boilerhouse chimney: (v) Ignition of timber from steam-pipes: (vi) Spontaneous combustion. We have carefully considered all the evidence given in respect of each possible cause. We think the last three causes—Nos. (iv), (v), and (vi) —may be eliminated. A number of witnesses were of the opinion that fire was caused by some fault in the electric-wiring system. The suggestions put forward to account for the fault were that it was caused in some way by the slipping nature of the soil on which the building stood. The evidence in this connection was neither very illuminating nor impressive. Mr. Young, electrical engineer to the Dunedin City Corporation, was of the very definite opinion that the fire was not caused by fault in electric system. While admitting possibility fire was electrically caused, it is not shown to our satisfaction that it was. We have not referred in any detail to the possibility of fire having been caused by the radio set installed in the building. The evidence given was that the set was not functioning at 2.30 p.m. of the afternoon of fire and that it was then disconnected by pulling the plug out of the wall and was not again connected. The action of rats affords a possible explanation of fire, but there is no evidence. The possibility that fire was due to the action of a patient cannot be disregarded. There is, however, no evidence which would justify us in coming to the conclusion that it was so caused. The possibility of any unauthorized person having obtained access to the building need not, we think, be considered. Considering all the possible factors, we are unable to offer any opinion as to the origin of the fire which can be of any value. We must leave the matter entirely open. (9) Are there any practicable steps that should be taken to reduce the fire hazards of the institution and similar institutions so as to avoid the rislt of occurrence of fire, risk of spread of fire, and risk of loss of life ensuing therefrom t In considering practicable steps for the reduction of fire hazards in mental hospitals we are of the opinion that there are certain matters of general application. Most mental hospitals in New Zealand were constructed many years ago and were designed and built according to plans not in accordance with modern ideas. The present view as given by all expert witnesses is that wards should be of one story and built on the villa system. Apart from the obvious advantages in other respects, one need hardly stress the advantage of such construction in reducing fire hazards.

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