Silent Protectors

May 16, 2025

Hospitals exist for the clinical care and wellbeing of human life. The day-to-day,
high-dynamic activity of a hospital environment is counterbalanced by processes that ensure safety measures are in place for the facility infrastructure to fulfill its purpose of preserving human life.

As Victoria’s largest public health service, Monash Health plays a vital community role across the south-eastern region of Victoria. With close ties to leading universities, and over 25,000 staff, the Monash Health footprint extends across Clayton, Kingston, Moorabbin and Dandenong campuses.

Nathan Semos, Executive Manager at A.G. Coombs Advisory is leading a team that assures that Essential Safety Measures within the Monash Health facilities are in place as intended, and in compliance with required legislation.

Essential Safety Measures are features and systems in buildings that exist to protect occupants in the event of a fire or evacuation.

With an established industry reputation in fire protection and Essential Safety Measures, and a previous executive role with the Fire Protection Association of Australia, Nathan appreciates the importance of correctly maintained and compliant Essential Safety Measures.

“Maintaining Essential Safety Measures goes beyond the life cycle servicing of mechanical and fire services systems. A.G. Coombs Advisory is playing an independent role in assuring that these building features and systems are maintained in accordance with regulations and that service providers are performing maintenance to the strict requirements.”

More than box ticking

In every state and territory of Australia, building owners and occupiers are legally required to properly maintain Essential Safety Measures (ESM) or their local equivalent. This involves conducting regular tests and inspections to ensure compliance, which supports the annual certification process.

Responsible for reviewing the Essential Safety Measures of 78 separate buildings in the Monash Health portfolio, A.G. Coombs Advisory works closely with the on-site Monash Health Engineering & Infrastructure teams to conduct required reviews, tests, and reporting. This process involves annual compartmentation inspections, quarterly egress inspections, review of maintenance records, witnessing of fire mode testing and the preparation of the Annual Essential Safety Measures Report.

The inherent complexity and criticality of hospital infrastructure and facilities means Essential Safety Measures requirements for healthcare assets are often more rigorous than for most buildings. And with 24/7 acute healthcare environments with intense operational requirements, hospitals can present nuanced challenges for Essential Safety Measures maintenance
and assurance.

Compartments Matter

The inspection and assessment of the fire and smoke compartmentation for each building within the Monash portfolio is vital. Hospitals have heavy reliance on fire and smoke compartmentation as well as active fire protection systems such as sprinklers, hydrants and mechanical air handling systems to protect occupants.

As a design approach to prevent fire/smoke from spreading rapidly throughout an entire building and to provide occupants additional time to evacuate, or be rescued, compartmentation of spaces within a building aims to create fire and smoke barriers using fire-rated walls, doors, floors, ceilings and works in combination with smoke hazard management systems.

A.G. Coombs Advisory assures that fire and smoke compartments are not compromised by facility or operational changes. The team works closely with Monash Health to mitigate future issues by assisting with building permit applications and helps oversee upgrade works as an independent advisor.

“Nathan and the A.G. Coombs team have an intricate working knowledge of our facilities and a deep understanding of the requirements for Monash Health to be fully Essential Safety Measures compliant,” says
Sujeevan Panagoda, Deputy Director, Infrastructure & Compliance, Engineering & Infrastructure at Monash Health. “Their attention to detail and proactiveness provides a high level of comfort and assurance for Monash Health operations.”

Annual independant testing

Whilst fire extinguishers, fire indicator panels, fire sprinklers, fire hydrants, fire
doors, and other fire protection system elements are regularly tested and checked, the annual independent witnessing and reporting of the systems interface test is a critical compliance step.

The A.G. Coombs team witnesses the annual Systems Interface Test to ensure that major essential fire safety systems interface and operate as required and comply with the design and operational
specifications set out in the Fire Mode Matrix for each building. During this test mechanical, electrical, and fire protection service providers operate the buildings in fire mode, with A.G. Coombs Advisory reviewing how the systems perform in relation to design requirements.

At larger facilities such as Monash Medical Centre and Monash Children’s Hospital at the Clayton Campus, these annual tests can take up to three days per location with the A.G. Coombs team observing testing, collecting data, analysing results, and preparing reports for Monash Health.

Working harmoniously

To facilitate the collection of data across 78 buildings, consolidate results and produce interactive reporting, a digital data management system is utilised.
Information and imagery are captured on-site in real time and the system supports the preparation of reporting and seamless data sharing with Monash Health.

For Nathan, supporting Monash Health goes beyond data and reporting. “When the Annual Essential Safety Measures Report is issued, there’s a real sense of achievement knowing that the work we have undertaken is an important contribution to the safe operation of a major healthcare service. The human aspect is truly rewarding.”