A Birmingham pensioner died in a bath of "virtually boiling" water at a respite hostel in an accident brought on by neglect, an inquest jury decided yesterday.
George Inwood, aged 68, was found lying naked in a staff bathroom at The Lodge, in Stechford, on April 1 last year after a paramedic kicked the door down. A lone support worker who heard his screams dialled 999 after she failed to get into the locked bathroom.
The jury of five women and three men returned a unanimous verdict of accidental death by which neglect contributed at Birmingham Coroner's Court after a two-day hearing.
It read: "It was evident that water from the system was dangerously hot and had been like this for some time and this situation had not been alleviated due to poor communications."
Coroner Aidan Cotter previously heard from a heating engineer, called in to test the hostel's system, who had recorded water running at up to 98?C.
Mr Inwood, of Horrell Road, Sheldon, also suffered a suspected heart attack that morning at the respite hostel in Yardley Fields Road, Stechford.
The former Rover worker, who suffered from Parkinson's disease as well as depression after his wife Beryl died in 2003, voluntarily used the centre occasionally as a place to sleep and receive his morning medication.
Staff at The Lodge, which is owned by Birmingham and Solihull Mental Health Trust (BSMHT) and run by Servol Community Trust, had reported water being "too hot" at least five months before his death, the inquest heard.
But yesterday a Health and Safety Executive inspector revealed a thermostatic mixing valve (TMV), which was set too high, had been found by mistake.
Catherine Carroll told the jury: "In truth, I found that nobody - not the trust, not Servol or Amey - was aware a TMV was fitted to the bath."
In November 2003, five months before Mr Inwood's death, a call was made to maintenance contractor Amey Business Services to request it be regulated.
But the firm said its help desk, through which clients phone in complaints, had not received a report about excessively hot water at The Lodge.
In his evidence, Charles Jordan, former chief executive of Servol, made a public apology to Mr Inwood's family.
He said: "We're sad this situation did arise and I do apologise for the fact that it happened."
The jury also heard how Mr Inwood, whose son Derek and daughter-in-law Debbie were in court, was noted as having mobility problems by his mental health team.
Hostel staff had already told the inquest that if the fatherof-three had asked to use the staff bathroom, he would have been allowed.
Diana Morgan, BSMHT's service director, read out extracts from Mr Inwood's file which clearly stated he needed assistance.
On February 21, 2001, it was noted: "He has some difficulties getting in and out of the bath, these problems have been there for a long time.
"Liaise with key worker re: referral to occupational therapist as to George's mobility. He needs help to get out of bed and bath."
Mrs Morgan added: " Workers at the Yardley Fields home provide support not care, so people that go there must be able to look after themselves, they must be self-caring."