This blog sets out some of the risks from scalding to which vulnerable people may be exposed when bathing or showering and the key measures required to protect them.
NHS England has in place a “never events” policy. A “never event” is defined as ‘a serious, largely preventable, incident that should not occur if the available preventative measures have been implemented by healthcare providers’. Scalding of patients and others is on the list of “never events”.
The Water Management Society published ‘Guidance on the Principles of Scald Risk Assessment in Domestic Water Systems’ in 2023.
Vulnerable People at risk from Scalding
The groups of people who are most vulnerable to scalding include:
- Older people;
- People with reduced capacity, mobility, or temperature sensitivity;
- People who cannot react appropriately or quickly enough, to prevent injury;
- People with complex medical conditions whose capacity may be impaired due to the medical treatment being received.
Hot Water Temperature
Hot water temperatures above 44°C for showering or bathing (full body immersion) represent an increased risk of serious injury due to scalding. When large areas of the body are exposed to high temperatures, scalding injuries can be very serious and could result in a fatality.
Water Hygiene Safety
Controlling water temperatures is an essential element of water safety. For example, to minimise the growth of waterborne pathogens and keep any associated risk of infection as low as reasonably practical, there is a need to circulate hot water at temperatures above 50°C (55°C in healthcare premises) and to ensure that cold water temperatures remain below 20°C. There is a requirement, therefore, to put in place measures to control the maximum hot water temperature at outlets in areas where vulnerable people are likely to access.
Scalding Risk Assessment
There is a need to undertake a scalding risk assessment to understand the risks and to inform the measures that will be necessary to prevent or control them. The risk assessment will include the water systems within the building from the incoming supply, the cold water storage & distribution, and all the plant equipment used to generate, store, and distribute hot water throughout the premises. The risk assessment will include all outlets e.g. wash hand basins, showers, baths, toilets, hi-lo baths, hot drinks boilers, and ancillary sinks.
There is also a requirement to carry out a general scalding risk assessment on each person receiving care, considering the following:
- Likelihood that the user will require the use of a bath or shower;
- Capability/competence of the person who will run a bath or shower - whether this is the user or whether there is someone else who might do this for them;
- Lack of mobility and or ability to respond to hot water i.e., being able to get out of the shower or bath if the hot water is too hot;
- Sensitivity to temperature;
- Having a mental state that cannot recognise or react to hot water;
- Ability to summon assistance;
- Complexity of medical condition.
To restrict the temperature of hot water at an outlet a Thermostatic Mixing Valve (TMV) is fitted locally to the outlet (wash hand basin, bath, or shower) to restrict the temperature. The desired output temperature will vary depending on the application, in non-healthcare premises hot water should not exceed 44°C and in healthcare premises, this is determined by the type of outlet following the guidance contained in the HTM 04-01: Supplement. Performance specification D 08: thermostatic mixing valves :
A Type 3 TMV is required in all instances for healthcare premises. Where there are electrically heated showers, the temperature control must be maintained in all conditions e.g. surge or reduction in cold water flow/pressure. The hot and cold water systems also need to be adequately maintained and monitored by competent staff.
There should be adequate training and supervision for staff involved in the care of people generally. The same is true for staff involved in the maintenance and monitoring of water systems in Health and Social Care premises.
What can go wrong?
A quick round-up of related news articles reveals that scalding problems are not uncommon. The summary below links to some interesting articles and highlights the deficiencies reported in each case:
Edinburgh hotel pays compensation over shower scalding death – although no Fatal Accident Inquiry was undertaken, questions were raised about whether the hotel failed in its duty of care by not having fitted a thermostatic mixing valve to regulate water temperature.
Ark Housing Association fined after death of man in bath scalding –The housing association pleaded guilty to two contraventions of the Health and Safety at Work etc. Act 1974. Ark was fined £75,000 and after cooperating with the HSE, steps to prevent future incidents were undertaken including installing thermostatic mixer valves where necessary, providing suitable thermometers, training staff and implementing written instructions for bathing and showering.
A woman died after Greencroft Residential Home scalding – No effective control over the temperature of the hot water at the premises, no risk assessment had been carried out and there had been little staff training, resulting in a £5,000 fine for breaching health & safety rules.
Care home to pay £145,000 over teenager's scalding death - An HSE investigation revealed that although the bath used was fitted with a special valve to prevent scalding, this valve was never set. Staff at the home were also found to have no training in managing the risks of scalding, nor was there a suitable bath thermometer in place. The precise bath temperature was unknown, but the taps could deliver water at around 66OC.
Housing association to pay £135,000 over scalding death – A 75-year-old sustained burns to 40 per cent of his total body surface area after water was at a temperature of between 60 and 65OC. Midland Heart, the largest housing group in the Midlands, admitted to two breaches of s3(1) of the HSWA 1974 for failing to ensure the water outlet temperature had been properly controlled to avoid scalding. They have subsequently invested money to minimise the risk of scalding accidents and installed thermostatic mixer valves on their baths.
Health and Safety at Work Act 1974 Section 3
Management of Health and Safety at Work Regulations Regulation 3
Provision and Use of Work Equipment 1998
L08 Legionnaires’ disease - The control of Legionella bacteria in water systems (2013)
HSG 274 Part 2 The control of Legionella bacteria in hot and cold water systems
HTM 04-01 Safe Water in Healthcare Premises Parts A, B and C 2016 (2014)
HTM 04-01 Supplement Performance Specification D08 thermostatic mixing valves (healthcare premises) 2016
HSE information sheet No. 6 - Managing the risks from hot water and surfaces in Health and Social Care (September 2012)
The Water Management Society ‘Guidance on the Principles of Scald Risk Assessment in Domestic Water Systems’ (2023)
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Editors Note: The information provided in this blog is correct at the date of original publication - November 2019. (Revised December 2023)
© Water Hygiene Centre 2023