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Courts and Tribunals Tasmania

RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Christopher P Webster, Coroner, have investigated the death of

Bela Marikovszki

Find:

(a) The identity of the deceased is Bela Marikovszki (‘Mr Marikovszki’);

(b) Mr Marikovszki died on 14 January 2013 at Royal Hobart Hospital; 

(c) Mr Marikovszki was born in the Czech Republic on the 11 December 1922 and was aged 90 years;

(d) Mr Marikovszki never married and his occupation at the date of death was retired;

(e) I find that Mr Marikovszki died as a result of multiple organ failure following extensive burns due to immersion in hot bathwater;

(e) At the time of his death Mr Marikovszki was not being treated by a medical practitioner.

Circumstances Surrounding the Death:

Mr Marikovszki was a 90-year-old man living alone at Eurobin Street, Geilston Bay in Tasmania. He had a history of renal impairment and dementia and was under regular medical monitoring. Despite these problems he was regarded as suitable for independent living and was assisted in his care with community care provided by Uniting Aged Care.

On 13 January 2013 at 11:15 AM a community care nurse found Mr Marikovszki lying in his bath naked with extensive burns over his body. He was transported to the Royal Hobart Hospital where he was diagnosed with extensive burns to over one third of his body. At that stage he had a poor prognosis and it was not considered that he would survive. He was treated in the intensive care unit and died 14 January 2013 as a result of multiple organ failure and severe acidosis as a result of the severe burns.

Police investigations did not reveal any suspicious circumstances. Investigations revealed that Mr Marikovszki had recently installed a new hot water cylinder as his previous cylinder was leaking. Testing of the water showed that the temperature of the hot water service was 60°C. The water system in temperature was confirmed to be compliant with current regulations.

Enquiries revealed that Mr Marikovszki was not known to have baths but rather showered. The deceased was not able to explain, after his discovery in the bath, how he came to be in the bath or how he suffered the burns. It appears that Mr Marikovszki, due to his dementia, became confused and decided to have a bath and that he was unable to adjust the temperature of the hot water or to get out of the bath due to his age and physical condition.

Comments and Recommendations: 

Care should be taken by or on behalf of aged persons or persons in poor physical conditions to ensure that if they have to bathe in a bath that they are safe. This could involve the fitting of taps that are easy to operate by aged persons or persons with disabilities and handrails or similar devices to enable the bather to get out of the bath with ease.

It has been suggested that in aged care facilities or in the homes of aged persons or persons with disabilities that the water temperature should be less than that prescribed by the current plumbing regulations. I do not recommend that there be any change in the water temperatures presently prescribed by the relevant plumbing regulations. The present water temperature is set to ensure that hot water supplies do not breed airborne respiratory diseases (such as legionnaires disease). Such diseases are likely to pose a greater hazard then any problems associated with the present temperature of the hot water systems.

I have decided not to hold a public inquest hearing into this death because my investigations have sufficiently disclosed the identity of Mr Marikovszki, the date, place, cause of death, relevant circumstances concerning how his death occurred and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999.  I do not consider that the holding of a public inquest hearing would elicit any significant information further to that disclosed by the investigations conducted by me.

Before I conclude this matter, I wish to convey my sincere condolences to the family of Mr Marikovszki.
 

DATED: 27 September 2013 at Hobart in the State of Tasmania.

 

Christopher P Webster
Coroner