Failure to control water temperature

A man with a severe learning disability, who is unable to talk, suffered scalding so severe his skin was left hanging from his body when his landlord and the agency providing his care failed to control the temperature of his bath water.
Paul Cundy, 64, lived in a rented home for people with severe learning difficulties in Eddystone Road, St Austell, at the time of incident on 27 December 2008.
The home owners, Comhome Ltd, and Solor Care Group Ltd, a domiciliary care agency, admitted safety failings after being prosecuted by the Health and Safety Executive (HSE).
In an earlier hearing, Truro Crown Court was told that Comhome provided housing for vulnerable people while Solor Care Group – then Robinia Care – provided care staff from another agency to work at the home.
Mr Cundy suffers with cerebral palsy and epilepsy in addition to his learning difficulties, is unable to talk and needs physical help with all aspects of daily life. He was unable to say that his bath water was too hot or get out unaided.
On the day of the incident, Mr Cundy was put into the bath using a hoist by a care worker. As he entered the water he immediately recoiled, prompting the worker to raise him out because she thought he was suffering a seizure.
Another member of staff checked the water by hand and added some cold before Mr Cundy was again lowered into the bath. He again reacted and began thrashing and moaning in pain. He was raised for a second time and staff noticed his skin was severely scalded and was hanging off on his feet, buttocks and elbow.
He was hospitalised for four weeks to receive treatment for 10% (second degree) burns.
An HSE investigation revealed there was no thermostatic mixing valve (TMV) fitted to the bath, which would have regulated the water temperature to below 44 degrees C – as recommended in national guidelines. A TMV had been fitted but was disconnected in 2002.
Four internal maintenance reports highlighted that the TMV for the bath wasn’t working and identified it as “high risk” because water from the tap was coming out at just under 60 degrees C.
There was no thermometer or formal control system for checking water temperature. Instead staff used a variety of unsatisfactory measures, such as checking by hand and elbow. HSE also found evidence of inconsistent and limited staff training.
Mr Cundy’s care plan, drawn up by Solor Care Group, contained no reference to risks of water scalding and there was no system to ensure carers had read or understood it.
Comhome Ltd of Edward Street, Truro, pleaded guilty to a breach of Section 3 (1) of the Health and Safety at Work Act 1974.
Solor Care Group Ltd of Circus Mews, Bath, also pleaded guilty to a breach of Section 3 (1) of the same Act.
HSE Inspector Jo Fitzgerald said:
“This appalling incident could and should have been avoided. It resulted in agonising pain for Mr Cundy, a vulnerable member of our society who was deserving of the very highest standards of care and protection.
“Comhome’s failures included failing to ensure bath water temperatures were properly regulated via an operating TMV, failing to work with Solor to resolve the issue with the TMV, and failing to act on repeated warnings by maintenance staff about the dangers of hot water where no TMV was fitted.
“Solor, in turn, also failed to ensure the TMV was working or to have proper systems in place to check bath water temperatures. They failed to provide proper training for staff, failed to provide a thermometer for the care workers, failed to properly assess scalding risks, and failed to follow its own company policies.
“Both defendants were criminally negligent in dealing with an obvious and potentially lethal risk.”
Further information on safe bathing in care homes can be found on the HSE website at http://www.hse.gov.uk/healthservices/scalding-burning.htm

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