The deadly fire at the Hadfield Street Drop-in Centre on July 8, which claimed the lives of siblings, Antonio and Joshua George, was a tragedy waiting to happen.The Commission of Inquiry (CoI) into the incident found it was a tragedy waiting to happen and that there was a collective responsibility for the tragic event, which claimed the lives of the George brothers. The report found the system to protect the children failed and therefore all players are collectively responsible. Six-year-old Antonio and his two-year-old brother, Joshua George, along with three other siblings were taken into the care at the Centre two days prior to their demise.Siblings Antonio and Joshua George perished in the fire on July 8The findings of the inquiry conducted by Retired Colonel Windee Algernon found that the children/staffer ratio was not adhered to and that on the morning of the fire, there were not enough staff members on duty to meet the needs of children. Additionally, the house service supervisor, while she had the authority to call out more staff, failed to do so.The CoI also found that there were written guidelines for the management of crisis situations, including fires; however, the house manager and other senior staff seemed unfamiliar with them. And so when the fire occurred, there was confusion and panic resulting in the tragedy.It also found that the staff on duty at the time cannot be entirely absolved, the two children died in her care. It pointed out that the administration of the Drop-in Centre in collaboration with the Childcare and Protection Agency (CPA) failed to ensure that she possessed the skill set to perform her responsibilities adequately. The CoI found that the fire was caused by a defective electrical point fitted with exposed wires on the eastern wall of the girl’s dormitory. This, the report said, played a role in the ignition of the fire by subsequent heat transfer.Along with the findings, the CoI made some recommendations, including that the Social Protection Ministry and the CPA continue to focus on overhauling child protection, cutting red tape and improving the skills and knowledge of social workers so that they could adequately protect children in the State’s care.It also recommends that the emergency evacuation plans be developed and practiced at all child care facilities, and that in house training, including rehearsals, be conducted for staff in crises management and child care centres. Recommendations were also made for an inspector to the homes and this appointment should be done immediately to ensure compliance with the Social Protection Ministry. It also recommended that the childcare workers be given additional time away from the working environment to allow them to relax after a period of work or tension and also that suitably satisfied staff be recruited to meet the increasing demands of child care responsibilities. Revealing the scope of the inquiry, the CoI report said it visited the Sophia Care Centre where children of the Drop-in Centre are now housed. Some 26 persons from the CPA, the Drop-in Centre, civilians and Red Thread were interviewed.The CoI was required to ascertain the causes, condition and surrounding circumstances which led to the deaths of the brothers, whilst in the care, control and custody of the State and to report on whether there was failure on the part of State officials to deal appropriately or adequately with matters which gave rise to the loss of lives and whether there were any unsafe or improper arrangements for the care, custody and welfare of the children.