April 2024. In the middle of the night, a beneficiary’s attendant intends to shout for help in a RPA in Trois-Rivières. She runs up and finds a 90 -year -old lady sitting in her bathroom with “an important redness with the whole right hand, similar to a burn”. A call is immediately made at 911.
In the hospital, a serious burn is confirmed on the entire hand. The nonagenarian is “very suffering”. Coroner Mélanie Ricard specifies in her investigation report that because of her cognitive problems, the lady is “unable to relate events in a coherent manner”.
His right hand is burned in the second and third degrees. It is transferred to the unit of the Gallows Brûlés at the Child Jesus Hospital in Quebec. It can be seen that the injury is “compatible with an immersion in immersion in hot water”.
The consequences are dramatic. We speak of “a necrosis of the adult and the annular”, that is to say the death of the tissues, relates the coroner. To hope to remedy it, it was necessary to consider “multiple amputation surgeries” and “skin grafts”, explains Me Ricard.
Doctors note that at 90 years old, with “a precarious state of health”, the risks linked to such interventions are “high”. The prognosis for remission is “weak”. In agreement with the family, a palliative approach has been adopted. The lady was able to return to the Center Hospitalier Affilié Universitaire Regional (Chaur) in Trois-Rivières, where she made her last breath a month later.
“During her hospitalization, she verbalized her loved ones that she wanted to clean himself and not with summer capable of removing her hand from hot water, despite a burning sensation,” writes Ricard. Unfortunately, given its already known cognitive state, it is impossible to establish by its words a reliable version of events. ”
Water to more than 53 ° C
The police investigation carried out at the Coroner’s request made it possible to exclude any intervention by a third party. A judicial identity team was able to carry out temperature tests at RPA, after making sure that no modification to the plumbing system had been made there since the incident.
In the deceased apartment, the temperature of the hot water of the kitchen and bathroom was slightly greater than 53 ° C.
The Coroner notes that from this 53 ° C threshold, the skin of an “healthy” adult will undergo second degree burns in one and a half minute.
“The skin of the elderly being thinner and less vascularized than that of a healthy adult, the required exposure times will be lower and the risk of burns increases,” said the report.
No maximum temperature
Me Ricard recalls that since 2013, the building management has imposed a maximum temperature of 43 ° C for showers of showers and baths in RPA and care establishments. “However, no maximum temperature is prescribed with regard to sinks,” she notes.
The Coroner stresses that several deaths have occurred in recent years due to burns caused by water.
Me Ricard’s report adds that RPAs are increasingly hosting “extremely vulnerable people who have increasingly important cognitive limitations”.
The lady burned her hand was also in such a situation. In the weeks preceding the incident, his RPA had reported an “overtaking of the service offer” at the integrated university health and social services center of Mauricie-et-du-Center-du-Québec for relocation to a better suited resource.
A avoidable death
Mélanie Ricard is not the first coroner to lift the question of the temperature of the hot water of the washbasin. His colleague Louis Normandin looked at a similar situation in 2013, following a death in a long -term accommodation and care center (CHSLD).
In his report of the time, Dr. Normandin recalls that the Coroner office had recommended, in 2010, that the water temperature was limited to 40 ° C in “service points, including sinks, CHSLDs and other private establishments”.
Me Ricard is convinced that in the most recent file, a temperature control device would have made all the difference.
“It seems obvious to me that such a measure limiting the temperature of the water at the exit of the taps of the sinks in the private residences for seniors could have avoided a death in this file.”
— Extract from the Coroner Mélanie Ricard ratio
“For the purpose of protecting human life”, the Coroner recommends that the Régie du Bâtiment du Québec (RBQ), in collaboration with the Ministry of Health and Social Services and Health Quebec, “take the necessary steps” to modify the Building code and the Security code “So that the maximum temperature at the exit of any tap available to a resident of a private residence for seniors or a care institution is limited to 43 ° C”.
The RBQ told information Coops on Thursday that it “analyzes” this recommendation “in a spirit of continuous improvement in prevention measures”.
The organization says that discussions take place “with the partners concerned in order to assess the impacts of a regulatory modification on this subject”, while stressing that “the lowering of the water temperature could cause legionellosis issues that will be considered in the solutions to be set up”.
RBQ spokesperson Laurent Bérubé also explains that the regulatory changes made 12 years ago were based on recommendations “which targeted primarily” the water of showers and baths, “where the risks of burns are generally higher”.
“At that time, the available data did not justify the explicit inclusion of sink taps in temperature limitation requirements,” he said.
Modified system
La Coroner also specifies that RPA – which is not identified – where the lady has remained since has made, “on her own initiative”, modifications to her plumbing system. “Temperature control devices have been installed” in order to limit the temperature of all sinks, baths and showers accessible to residents to 43 ° C.
Other devices allow the use of warmer water in places not accessible to residents, among other things for the dishwasher.
