An elderly resident at a local nursing home, who died following an epileptic fit, may have suffered the fit as a result of shock after being bathed in scalding hot water. Eighty-two-year-old John Heywood Davies, known as Jack, was a resident at Brooklands Nursing Home, Narberth Road, near Saundersfoot, when he died in March of last year. A verdict of death by natural causes, aggravated by want of care, was recorded by Pembrokeshire Coroner Mr. Michael Howells at an inquest in Milford Haven on Monday. Following the verdict, Mr. Phil Charret, principal inspector with the Health and Safety Executive, said an investigation may now take place. "In view of the verdict, we will look at the facts of the case to decide whether further action will be taken," he stated. After being found in his room in a soiled state, Mr. Davies was given a bath by three carers at the home who were on night duty at the time. Described as having aggressive tendencies when bathed, Mr. Davies, who suffered from epilepsy, dementia and heart and brain degenerative conditions, was lowered into a portable bath by the carers who proceeded to wash him. "Only after 10 minutes of sitting in the bath did Jack complain of the water being too hot, which was when I checked it with my arm," South African nurse, Patience Ngobu, told coroner Mr. Howells. Assisting nurse Patience in bathing Mr. Davies were carers, Martina Joseph and Grazina Mostovojiene, who admitted in a police statement to running the bath water, but not checking the temperature on the thermometer on the bath, which featured a fail-safe control to prevent the tap from running water exceeding a temperature of 43 degrees. Three carers who worked at the home and were just starting their morning shift at 7.30 am, described events when they arrived on duty, hearing a commotion coming from the bathroom. "We just thought it was Jack being Jack, but when I popped my head round the corner to tell him off, I could see Grazina vigorously throwing jugs of cold water over his legs as Patience continued to wash him in the bath," said one of the carers, Louise Davies. "The floor was a complete mess in the bathroom with water everywhere. "I could also see that Jack's legs were red raw from the bottom of his feet to the top of his thighs; that's when I went to the office to wait for the home's deputy manager, Mike Bridge, who was also due to start his shift," she added. After being alerted to the commotion, Mr. Bridge described how Mr. Davies, who had now been moved to his bedroom, started to fit. "His limbs were shaking and twitching; he eventually stopped breathing and the ambulance was alerted." After being called to the scene, Dr. Allen, of Saundersfoot Surgery, examined Mr. Davies and found extensive blistering to his legs. He also revealed that the shock of being placed in hot water could have put him into a state of cardiac arrest. Following the incident, the fail-safe tap on the bath was examined by the HSE. "The tap could have a mechanical fault or could have been altered to allow it to deliver temperatures higher than 43 degrees, which is something we are still looking into," principal inspector, Mr. Phil Charret, told the coroner. On delivering his verdict, Mr. Howells said: "Because of the many facets of the pathologist's reports into Mr. Davies's death, it is impossible to put a finger on any one cause. "I have no doubt that all the carers on duty that night were qualified and competent enough to have been taking care of Mr. Davies in this situation. However, a full lack of command of the English language between the three, who all hailed from different countries, may have led to inter communication problems arising when checking the bath water's temperature. "The shock of being placed in scalding water may have resulted in cardiac events, and in light of the medical and pathological reports, I have concluded a verdict of death by natural causes aggravated through a lack of care by persons unidentified," stated Mr. Howells.
