Mrs Norris, a dementia patient at Birdsgrove Nursing Home in Bracknell, died three days after the incident in 2015. She suffered serious burns to 12% of her body following being in the bath for around 10 minutes. Care home owner, Aster Healthcare, later falsified water temperature records submitted to the Care Quality Commission and the Health and Safety Executive (HSE). The company also rewrote meeting minutes and attempted to mislead the subsequent investigation.
Investigators from Thames Valley Police and the HSE discovered the home had a history of issues with its hot water systems. Additionally, there was no proper bathing policy in place, and staff were not adequately trained to provide a sufficient level of care for the residents.
The investigation found there had been a longstanding problem with regulating the hot water supply and Aster Healthcare had not followed the available guidance for the safe provision of hot water. The bath used by Mrs Norris was not fitted with the correct type of thermostatic mixing valve. The one that was fitted had not been serviced, and was not working correctly.
Care home manager Elisabeth West was given a nine-month jail term, suspended for 18 months, while carer Noel Maida was sentenced to 16 weeks, suspended for 18 months. Both were sentenced under failure to discharge a duty. Aster Healthcare was fined £1.04m on one count of corporate manslaughter, plus prosecution costs of £184,513.
In healthcare settings, Type 3 TMVs are the standard required by the Department of Health’s Health Technical Memorandum 04-01, The control of legionella, hygiene, ‘safe’ hot water, cold water and drinking water systems. Type 3 TMVs should be installed when older TMVs are replaced or where there are new installations. It’s vital that TMVs receive annual servicing from a qualified professional and that in baths and showers not fitted with Type 3 TMVs, other controls of equal effectiveness, are in place to reduce the risk of scalding.
Kevin Wellman, Chief Executive of the Chartered Institute of Plumbing and Heating Engineering (CIPHE), warns that lessons are still not being learned on care home scalding incidents.
He said: “In the case of Mrs Norris, the care home’s negligence is astounding. A bath water scald is just as serious as a burn from fire, yet they knowingly exposed residents to a faulty hot water system with devastating consequences.
"We have the technology to stop scalding incidents all together. The CIPHE urges care homes and healthcare settings to ensure their TMVs are Type 3 and regularly serviced. It's time to stop putting profit above people.”
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