Care blunder lef t woman to die in hot bath
Tragedy was preventable, says sheriff
Margaret Gilchrist died after suffering burns on up to 90 per cent of her body.
A fatal accident inquiry has found Miss Gilchrist’s death would have been avoided if the carer had not left the hot water tap running and had carried out regular checks on her.
The 50-year-old, who had severe learning difficulties, was registered blind and had epilepsy, was being cared for by Enable Scotland worker Mary Cameron when the tragedy happened in Carntyne, Glasgow.
Miss Cameron had left Miss Gilchrist in the bath for more than 30 minutes while she carried out other duties.
A thermostatic mixing valve (TMV) to control bath temperatures should have been fitted by housing bosses three years earlier but an older version left in place malfunctioned.
When the carer discovered Miss Gilchrist unresponsive in the bath, she called for an ambulance but Miss Gilchrist was pronounced dead ten minutes after the call was made.
Miss Cameron was sacked by Enable following the death. Sheriff Lindsay Wood said Enable did not have adequate safety measures in place in respect of the bathing of Miss Gilchrist.
In a written determination following the FAI at Glasgow Sheriff Court, Sheriff Wood said: ‘Margaret Gilchrist died on September 26, 2013, in an accident which was preventable.
‘Mary Cameron did not ensure the hot water tap was turned off before she went downstairs. As a result, the hot water continued to flow and the temperature became excessive as the TMV did not function properly.
‘Mary Cameron had left her in the bath for longer than usual, certainly in excess of 30 minutes. If she had been checked regularly, Mary Cameron may well have seen the distress being caused and might have been able to do something about it.’
He added: ‘The accident might have been avoided if the hot tap was not left running and if visual checks had been made every three minutes or less. Mary Cameron committed an enormous human error.’
Enable Scotland’s procedures in relation to risk assessment of bathing have now been changed and a spokesman said: ‘We will reflect on the full findings.’
A Glasgow Housing Association spokesman said: ‘We are reviewing all aspects of the sheriff’s determination, notwithstanding that in respect of matters which might have contributed to Margaret’s death, he offered no criticism of GHA.’
In a statement, Miss Gilchrist’s family said: ‘The sheriff has addressed the main factors, given the limitations of the FAI, and there is not a lot more he could have said.’