An inquiry finds sufficient risk assessments weren't carried out

A Fatal Accident Inquiry (FAI) into the death of a vulnerable woman has found that social care provider Enable Scotland failed to provide sufficient risk assessments to avoid the tragedy.

In the FAI report’s conclusions, Sheriff Lindsay Wood made clear that failure to have a sufficiently detailed risk assessment in place was a contributing factor in death of Margaret Gilchrist.

The 50-year-old, who had severe physical and learning disabilities, requiring round-the-clock care, died from scalding after her carer, Mary Cameron, erroneously left on a faulty hot water tap.

Margaret shared her house with another service user but, the report found, that there was no form of risk assessment carried out in relation to the bathing other than a cursory check on the water temperature.

The report also highlighted that if anything happened to the other service user – who was prone to seizures – there could be challenges for a single support worker in caring for both service users at the same time.

The sheriff noted: “There was not a sufficiently detailed risk assessment in respect of the bathing of Margaret in conjunction with a related bathing plan which emphasised that staff had to ensure that the hot water tap was completely switched off after running a bath and to carry out visual checks on Margaret when she was in the bath every three minutes or less.”

The sheriff also found the bathing plan for Margaret was "defective" as it "did not stress the need to turn off the hot water tap and failed to specify the frequency and nature of checks to be made during the period Margaret was left to relax in the bath".

The inquiry heard of a similar scalding incident involving the vulnerable woman in November 1998, during which she "squealed, which was described as an unusual sound but not a loud one".

Crucially Margaret was unable to raise the alarm or call for help because of her learning disability, the judge found.

He said: "Margaret's ability to summon assistance whilst in the bath was compromised due to her learning disability and she would very rarely be able to vocalise when she was in pain.

"She would not cry if she was in pain and would also 'go into herself' if unwell. She could be vocal and made loud noises but she could not shout for help."

Forensic pathologist Dr Julie McAdam told Glasgow Sheriff Court Margaret’s body was scalded all over – about 80% to 90% – in a way that was consistent with it being partly immersed in water.

She said it was also apparent that parts of her body were scalded in the water after she died.

A spokesperson for trade union Unison, which represents care workers at Enable said failure to have a sufficiently detailed risk assessment in place was a contributing factor in Margaret’s death.

"It is vital that all care providers have sufficient risk assessments in place to ensure the health and safety of service users and the staff who care for them," he said.

“We hope lessons will be learned across the care sector to ensure this never happens again.”

Enable Scotland has since terminated the Mary Cameron's contract.

A spokesperson for Enable said: “The thoughts of the Enable Scotland family are with Margaret, who was a much loved lady.

"This was a tragic incident, and today we are thinking of all who knew and loved Margaret.

“The inquiry identified an area of the working system, which at the time of the incident in 2013, could be improved upon; and acknowledged that Enable Scotland took prompt action at that time to address it.

“We will now further reflect on the full findings made in the determination.

"The dignity and wellbeing of the people we support continue to be our highest priorities.”