Fire safety plans at a residential care home where a blaze killed 14 residents were "systematically and seriously defective", a fatal accident inquiry has concluded.
The fire at Rosepark care home in Uddingston, Lanarkshire, broke out in a cupboard overnight on January 31 2004 and ripped through the building. Four people were also injured in the fire.
Sheriff principal Brian Lockhart has published his findings following a 141-day inquiry.
He found that "some or all" of the deaths could have been prevented if the home, run by Anne and Thomas Balmer, had a "suitable and sufficient" fire safety plan.
Mr Lockhart concluded: "The management of fire safety at Rosepark was systematically and seriously defective. The deficiencies in the management of fire safety at Rosepark contributed to the deaths."
The inquiry, held at the Gospel Literature Outreach Centre in Motherwell, was told that the care home's practice meant a member of staff had to find the source of the blaze before dialling 999. Staff waited nine minutes before they contacted the fire brigade, the inquiry heard.
An extra delay, of just over four minutes, was added when the fire brigade went to the wrong entrance to the home. Lanarkshire Health Board had a "deficient way of working" which failed to pick up on fire risks within Rosepark, the determination found.
The health board, responsible for inspecting the home between 1992 and 2002, had an "inadequate appreciation" of its responsibilities under the Nursing Homes Registration (Scotland) Regulations 1990.
Mr Lockhart said the board had a "fundamental misunderstanding" of the role and responsibilities of Strathclyde Fire and Rescue and a "mistaken belief" that fire services were responsible for inspecting the home for fire risks.
A spokesman for the owners of Rosepark Care Home said: "Our legal team is studying the determination issued by Sheriff Principal Brian Lockhart. We have nothing further to add at present."