A 93-year old nursing home resident suffering from dementia was put into a scalding bath by a junior carer.After a few minutes the carer realised that the water was too hot. The resident was taken to hospital with serious burns covering 12% of their body and died three days later.Upon investigation by the CQC and HSE it was found that the water monitoring records had been falsified as well as evidence there had been an ongoing problem with the hot water, known to the home manager. The owners of the home were fined £1.04 million and ordered to pay prosecution costs of £184,513 after admitting corporate manslaughter. The manager pleaded guilty to charges under the Health and Safety at Work Act 1974 and was given a nine-month prison term and the carer 16 weeks with both sentences suspended for 18 months. The home closed a year after this fatal accident. All because of a seemingly simple scalding bath.The risk of scalding is a significant hazard in premises with vulnerable residents or visitors, which means the temperature at the taps should be controlled.
Review whether the hot water system is in a safe condition for such users
Ensure there are the necessary procedures in place for checking the bath temperature before use
Record the temperatures of the incoming and out-flowing hot water each month
Do not turn down the temperature of the hot water risking Legionella
Fit & maintain thermostatic mixing valves to hot taps – check the HSE website for further advice on the standards of these devices
Display “Warning, Hot Water” signs at any taps not temperature controlled
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