Author(s): Matthew Foley. Published on January 1, 2020.

Behind Bars

The St. Elizabeth's Mercy Hospital Fire of 1950—Davenport, Iowa


On January 7, 1950, 62 patients were locked in St. Elizabeth’s, the women’s psychiatric ward of Mercy Hospital in Davenport, Iowa. The two-story building was nearly 80 years old and was the oldest of Mercy’s four buildings. There were no sprinkler or fire alarm systems, and the windows of patient rooms were covered with metal bars.

The patients were attended by a nurse and her aide, and included a woman who had been locked in isolation. This was an abnormal treatment for her; enraged, she used a contraband cigarette lighter to ignite a curtain in her room. No one noticed the flames until it was too late.

Around 2 a.m., an employee in an adjacent building saw the flames spilling from St. Elizabeth’s and told his coworkers to call the fire department. He raced to the burning building to investigate but was turned away by the growing fire. Firefighters arrived on the west side of the building to find flames erupting from some of the windows; behind other windows they could see silhouettes of the women pressed against them, behind the bars, backlit by the glow of the raging fire.

The ward had no evacuation plan, and locked doors prevented movement inside the building. Outside, many rescue attempts were thwarted by the barred windows—firefighters had to chop the bars out of each wooden window frame to reach patients trapped in their rooms. “They weren’t screaming and didn’t seem excited much. They just looked bewildered,” recounted one patrolman who assisted with the rescues. “Sort of like creatures who had something new happening to them and didn’t know just what to do.”

The fire killed 40 of the ward’s patients, along with the on-duty nurse. Responders rescued 22 patients, and the nurse’s aide fled after being wakened by screams. “I didn’t relish the prospect of jumping from the third floor,” the aide explained in a newspaper account of the fire. “If I hadn’t gone when I did, I might have been trapped like the others.”

The fire department would later discover that the west side of the building was actually the more manageable side. A light wind had carried flames across the hallway, creating an inferno on the east side that would leave no survivors. “There was very little screaming in the part of the building where I was, but I could hear terrible, terrible yells from other parts of the building,” one patrolman noted.

An investigation revealed critical deficiencies that exacerbated the fire. The fire department had recommended a sprinkler system for the facility for more than 25 years, but it had never been installed. The absence of fire protection systems and an evacuation plan, along with locked egress doors and barred windows, led to a reevaluation of the fire hazards in health care occupancies that had been neglected for most of the era.

MATTHEW FOLEY is a junior applied researcher at NFPA. Top photograph: Getty Images