THE hotel fire that killed a couple more than three years ago was started by embers in fireplace ash put in a plastic bag next to kindling and newspapers.
A night porter on duty at Cameron House, and the hotel's management, pleaded guilty to safety violations that led to Simon Midgley, 32, and Richard Dyson, 38, dying from smoke inhalation and fire gases.
At a hearing at Dumbarton Sheriff Court in December, Christopher O'Malley, 35, of Lennox Street, Renton, admitted failing to take reasonable care for the health and safety of persons affected by his actions or omissions, namely the guests of the hotel which led to the death of the two men.
And at the same court on Friday, when restrictions on the reporting of last month's hearing were lifted, the hotel's owners pleaded guilty to two charges.
Between January 14, 2016 and December 18, 2017, they failed to have a system in place for removal and disposal of ash and embers, to maintain and empty ash bins, and failed to keep cupboards containing potential ignition sources free of combustibles.
They also failed to take fire safety measures necessary to keep employees safe and to keep guests safe.
A catalogue of failures by Cameron House management was exposed in the investigation, which took almost three years.
Two independent inspections in 2016 and 2017, as well as a Scottish Fire and Rescue Service (SFRS) annual audit in August 2017, explicitly told the high-end hotel not to store kindling and newspapers in the concierge's walk-in cupboard. A reminder letter was sent to the management just three weeks before the fatal blaze.
The said it was "unacceptable" to have combustible materials next to a mains electrical installation. This was found on 10 instances over a period of 18 months.
Yet hotel management did nothing.
While the Loch Lomond hotel - with a turnover of £21 million in 2017 - had a written policy for landing helicopters, it did not have any such policy for disposing of ash from its open fires.
And on the morning of the fire, the duty manager failed to take the guest register out when the hotel was evacuated, leaving firefighters unaware of missing guests for more than an hour.
Family members of the couple burst into tears as details were read out last month revealing how the men were found in the fire exit stairwell next to their room, having been trapped by smoke and almost zero visibility.
Mr Midgley's family - mother Jane and siblings Nicola and Jack - and that of Mr Dyson - father Rodger and step-mother Valerie - were all from Yorkshire. Members of the family were in court on December 14 for O'Malley's plea.
The court heard that Mr Midgley was a freelance travel journalist based in London and was in Glasgow in December 2017 planning to write an article promoting the area.
His partner of six years, Mr Dyson, a freelance TV journalist, joined him and they checked into room 8 of Cameron house at 3.30pm on Saturday, December 16. They planned to leave on Monday.
There were 214 guests in 96 rooms at the hotel on the night of the fire, including 25 children.
Advocate depute Michael Meehan QC told December's hearing in the early hours of Friday, December 15, O'Malley and a second porter were seen on CCTV going to empty the ash from the fireplace.
A supervisor chastised them for using a plastic bag to empty ash as it was a "fire hazard".
The porters were seen using a silver ice bucket to scoop out the ashes and a plastic bag with water in it. They were not told a correct procedure.
Metal bins at the back of the hotel for ash were overflowing and rusting at the bottom.
On Sunday, December 17, at 3.57am, O'Malley emptied ash from the Cameron Grill restaurant fire into a plastic bag. The more experienced porter chatted with him and watched.
The bag of ash was put in the cupboard near a stack of timber kindling. They closed the door.
At 6.39am a pre-alarm went off and O'Malley is seen on CCTV running around looking for signs of the fire, before spotting smoke coming from the cupboard.
When he opened the door, the fire immediately took hold and spread into the hallway.
Attempts to fight the blaze with a fire extinguisher were quickly abandoned and the hotel alarm was sounded and 999 called at 6.41am.
Four appliances and an aerial rescue unit arrived about 10 minutes later, having been told en route there were people trapped.
But the manager had not taken the guest register or the evacuation bag when they left. A firefighter had to retrieve them.
It wasn't until 8am that two guests were discovered to be missing.
Rescue crews checked room 8 and found it empty.
Another eight appliances arrived on site.
A couple in room 5 crawled along the floor to escape the thick smoke. Another couple with an infant on the second floor retreated to a balcony before they were rescued.
There were significant voids in the walls and ceiling of the cupboard. And because of voids in the walls, the smoke detector went off on the second floor before the first. The fire spread quickly.
Firefighters with breathing apparatus entered the escape stairwell near room 8 and found Mr Dyson on the landing at the top of the stairs with heavy deposits of soot on his face.
There was no sign of life.
Paramedics on site tried to resuscitate him and he was rushed to the RAH in Paisley where doctors also tried to revive him. They were unsuccessful.
A second team found Mr Midgley a short time after his partner behind the door to the landing where Mr Dyson was. Paramedics were unable to save him.
The fire continued to spread, and firefighters described seeing flames inside the walls on the first floor above the reception area and from the third floor.
The roof collapsed. It was not until the next evening, December 19, that crews stood down. And it wasn't until April 3, 2018 that the structure was safe enough for investigators to enter.
O'Malley was formally interviewed by police on March 20, 2020 and agreed to plead guilty in October.
Mark Stewart QC, defending, said his client expressed his "deepest sympathy and condolences" and that he "deeply regrets his actions".
But he said that while O'Malley was culpable, his actions were not deliberate or wilful. He outlined a catalogue of training failures and a lack of procedures, as also highlighted by the Crown.
Mr Stewart said O'Malley had been working in the technology sector before deciding on a career change and starting work at Cameron House on April 17, 2017.
He had e-learning training courses in his first week, and even on December 15 before the fire. The courses included everything from first aid and food hygiene, to dealing with bombs and preventing terrorism.
Open fires at the hotel were started during colder months by the day staff, and night staff were expected to clear them, though it was not part of the night porter's duties.
WATCH: CCTV footage shows how fatal hotel fire took hold
O'Malley had no experience with open fires and there was no training, no personal protective equipment, and no safe operating procedure ever existed. The task was never risk assessed.
Mr Stewart said experts had identified how embers could easily be hidden within ash and continue smouldering for three or four days. That information was never given to his client.
He told the court: "No formal training of staff was given to new starts. [There was] no assessment of their experience with open fires."
O'Malley had been shown how to clear ash by a colleague using a pan from the kitchen - and kitchen staff had complained about porters using their equipment to empty ash. But still nothing was done.
The ash bins were "not fit for purpose" and could not be emptied safely because they were rusting.
No department at the hotel has responsibility for emptying them.
The defence QC said: "One porter said he was amazed at the ignorance of removing ash and made fun of Mr O'Malley attempting to do so.
"Whatever training was given was inadequate to say the least, and management was unaware this was inherently dangerous."
Further, the hotel was aware of the risks after fires in 2010 and 2012.
"These were known to have happened by management," said the QC. "The night manager was aware of it.
"But they occurred prior to Mr O'Malley's employment and no danger was conveyed to him.
"No steps were taken to properly train or equip staff. No lessons learned, no correct operating procedure, despite what are clear warnings."
External reports on January 14, 2016 and January 25, 2017 warned the hotel about the lack of safe operating procedures around the emptying of ash.
Ash was sometimes cleared by kitchen dishes, plastic food containers, bin lids and cardboard boxes, sometimes using water to cool them.
Report recommendations included leaving grills for 12 hours before the ash is cleared out.
Instead, night porter staff were encouraged to clear ash within six hours or less of a fire going out. In one case, it was as early as 10.36pm.
SFRS warned combustible materials should not be stored in the cupboard. The report said it was "unacceptable", particularly with a danger of fire spreading through a building of such age, construction and the threat of voids being present.
But an email from the resort manager called only for "concierge cupboard to be tidied and holes filled".
A reminder letter from SFRS was sent to the resort manager on November 21, 2017.
A member of management took pictures of the cupboard with his phone and sent it to the concierge mailbox asking them to "make [it] safe".
Night porter staff were never told about the inspection, or that kindling and newspapers should not be stored in the cupboard.
Mr Stewart said his client's interaction with his colleague and manager before 2am on the morning of the fire showed he was the junior member taking direction from others.
The QC concluded: "Mr O'Malley was asked to carry out a task for which he was never properly trained."
At the hearing on Friday, Peter Gray QC, acting for Cameron House, extended his client's "deepest sympathies" to the families.
He said: "The accused organisation takes its duties to ensure the safety of both its guests and staff extremely seriously and, in relation to fire safety, had in place in December 2017, a detailed suite of measures designed to ensure the safety of all."
The QC argued the failings were "isolated" and did not show "systemic failings".
He said: "It was truly a matter of the greatest concern and remorse in equal measure. And perhaps inevitably as a response there has been much soul searching and a root-and-branch review was undertaken.
"The message has already hit home and hit home very hard."
In December, Sheriff William Gallacher said the fire was an "unmitigated tragedy" and expressed his "sorrow and sympathies" to the families of the two men.
He called for social work reports on O'Malley to be prepared ahead of sentencing on January 29, when Cameron House will also be sentenced.
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