Elderly patient died days after scalding accident

AN ELDERLY man with Alzheimer’s disease suffered severe burns when he flooded his room in a hospital’s psychiatric unit with scalding water from a hot tap.

The first and second degree burns covering almost 12% of John Ring’s body led to a fatal heart attack several days later, Cork City Coroner’s Court was told. However, Mr Ring’s family wasn’t told about the burns incident for almost two days, and it was a further two days before he was transferred to the hospital’s plastic surgery unit.

The details of the tragic circumstances surrounding the death were outlined to Cork’s city coroner, Dr Myra Cullinane, yesterday.

Mr Ring, 85, lived at the Powdermills nursing home in Ballincollig until he began to display increasingly challenging behaviour.

He was admitted to Cork University Hospital’s (CUH) 46-bed GF psychiatric unit on December 3, 2010, for a period of assessment, and was placed in a single room on its ground floor.

Mr Ring was mobile with the use of a walking aid, but nursing staff said he was difficult to manage, couldn’t take instructions and had difficulty communicating.

Nurse Denis Cremin said Mr Ring was asleep when he came on night duty at 7.30pm on January 5 last and that he was checked two more times before medication rounds began at 10pm.

He went to Mr Ring’s room at around 10.40pm and found him standing over an overflowing sink of scalding hot water. Mr Ring was standing barefoot in water on the floor.

Mr Cremin raised the alarm and several nurses had to prise Mr Ring’s hands off the sink. “He was distressed, not shouting, but he was making noise. He was crying,” Mr Cremin said.

When they got him back into bed they discovered severe scalds to his thighs, legs and his left arm.

The doctor on duty was called and she liaised by phone with doctors at CUH’s plastic surgery unit who suggested the application of a special gel and dressings to the wounds.

Mr Ring was made comfortable and slept the night.

It was 1.30am before the emergency was dealt with and GF staff decided it was too late to notify Mr Ring’s family. Despite instructions to day staff who came on duty later to contact the family it was Friday before they were told.

Plastic surgeons assessed Mr Ring in his room on Thursday but he wasn’t transferred to their unit until Sunday, January 9. But his condition deteriorated and he died on January 19.

Con Lynch, a night superintendent with the HSE’s South Lee Mental Health Services, said it was “far from ideal” that a patient with Mr Ring’s needs was placed in GF.

“I would question whether we are equipped to deal with it,” he said.

He said January 5 was a very busy day in the unit.

Mr Lynch said in the event of emergencies it is protocol to contact CUH’s emergency department. But he said the doctor on call was responsible for directing Mr Ring’s medical care.

He said he made a written note, and told day staff early on January 6 to inform Mr Ring’s family that day.

Following an internal review the temperature of the water flowing from hot taps in GF has been reduced, and families are now told immediately about incidents or accidents, he said.

Dr Cullinane described the case as tragic and recorded a verdict of accidental death.

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