He said problems with Rosepark's practices, including leaving residents' bedroom doors open at night, not calling the fire brigade immediately and failures in fire drill training for staff, should have been uncovered by the health board during its inspection.

BBC: Rosepark care home deaths 'preventable' inquiry finds

Its legendary operational drill entails everything from training drivers to hold their keys on a pinky finger so they don't waste time fumbling for them in pockets to asking employees to clean off desks at day's end so they can be clear for takeoff in the a.m.

FORBES: Logistics in Brown