Family of man scalded to death in care demands government action after inquiry

A family who lost their son after a horrific scalding incident at a group home wants to see more concrete action from the province, not simply procedural recommendations.

A judge has concluded that restricting shift lengths and consecutive days worked could help prevent scalding incidents, like the one that killed the Calgary man almost five years ago.



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    David Holmes, 35, died in hospital a month after he was burned in a bath Oct. 23, 2011 at Glamorgan House, a group home operated by Supported Lifestyles Ltd. (SLL). The non-profit housing society is under contract with the Persons with Development Disabilities Program (PDD).

    Holmes suffered from a form of severe epilepsy and was unable to speak. He couldn’t tell his care worker that the bath she was drawing for him was scalding him.

    The worker claimed to have checked the water temperature with her hand before letting him get in it and reported leaving him for a moment to open the door for the new employee, who was supposed to join her.

    When she returned to Holmes, she sprayed water on him, directly from the faucet, and only then realized that it was too hot.

    The attendant and her colleague then observed blistering and peeling on Holmes’ fingers and toes, prompting them to make their first call to the on-call weekend supervisor, but there was delay before the supervisor responded.

    After further examination of his body, they were directed to arrange for immediate transport to hospital, but neither of them called 9-1-1.

    It was almost three hours before Holmes was treated in hospital.

    Doctors at the Rockyview Hospital emergency department determined that Holmes’ skin showed partial thickness to feet, buttocks, perineum and left upper extremity, consisted with a “submerge and burn” incident. Holmes was immediately directed to Foothills Hospital burn unit.

    Despite undergoing several skin graft procedures, he died from his injuries on Nov. 26, 2011.

    In her report, the judge proposes the implementation of measures such as restricting lengths of shifts or consecutive days of work, in order to manage the role that stress, burnout, and “compassion fatigue” plays in incidents of error for persons with disabilities.

    “This recommendation is based on the recognition that the individual care attendant is key to preventing and responding to injury or other mishaps,” said Shriar.

    SLL founder and former chief executive officer George Gentleman said in a statement that the Glamorgan House’s safety standards were based on Alberta Council of Disability Service’s Creating Excellence Together Standards (CET), which included emergency protocols but not bathing protocols, water temperatures, or maintenance and safety checks regarding water temperature.

    Since Holmes’ death, two other scalding incidents have occurred, prompting changes like the installation of anti-scald devices at more than 1,000 group homes.

    Minister of Human Services Irfan Sabir said in a statement Tuesday, “my thoughts are with Mr. Holmes’ family.”

    He went on to say, “we are committed to working with agency staff and our community partners in service delivery to continue making improvements and implementing best practices. We must learn from this incident and do more to consider credentials and training in the PDD service delivery sector. We will be examining this sector as part of the second phase of our PDD safety standards consultation to address qualifications, recruitment, and retention in this valued workforce.”

    David’s father Bob Holmes said over the phone Tuesday that he was encouraged by the judges recommendations, but wanted to see more immediate action by the government.

    “At some point we need to get beyond good intentions and assurances that people care and get into making some concrete changes.”

    “The judge, in the way that she phrased her recommendations, is clearly saying that the investment in better qualifications, better training, better support for front-line staff,” Holmes said. “That’s the area where the next round of improvements have to occur – not buying more thermometers and temperatures gauges and writing bathing protocols.”

    Holmes said David paid a “high price” for the changes that have been made around bath procedures so far, but more need to be made to improve the quality of care for other vulnerable Albertans.

    -With files from Tracy Tapang