Marjorie Nesbitt · Prevention of Future Deaths report

On the 17th September 2015 I commenced an investigation into the death of Mrs Marjorie Nesbitt (aged 97). The investigation concluded at the end of the inquest on 14th June 2016. The conclusion of the inquest was that Marjorie Nesbitt had died of hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema with old age and frailty as contributing factors.

I returned a conclusion of misadventure noting that Mrs Nesbitt had requested her carers to increase the power of her convector heater but that this then remained on overnight causing a very hot room. Mrs Nesbitt’s condition was such that she could not regulate her own body temperature.

Marjorie Nesbitt lived on her own with carers attending four times a day. There is no complaint about the conduct of the carers at any time.

On Friday, 11th September 2015 carers noted sparks within the vicinity of a wall socket where two items were plugged in. One was the power move to Mrs Nesbitt’s bed, the other was an oil filled free-standing radiator which was generally the major regulator of temperature in the room.

The company providing the carers caused an electrician to attend almost immediately and it was noted that the socket was defective and that the plug to the oil filled radiator was partly melted. No doubt all of this would have been fixed in due course but the immediate action of the electrician was to say that the socket and in particular the oil filled radiator with its defective plug could not be used again until mended and checked. The carers, and indeed Mrs Nesbitt were keen to follow this advice. The only remaining heating device for the room was a fan heater which was away from the immediate area of the bed and was left during the day on its lowest setting, providing a comfortable atmosphere.

However, at the time of the evening visit there was discussion between the carers and Mrs Nesbitt leading to the fan heater being turned up, most likely to its second setting out of three. Unfortunately Mrs Nesbitt was bedbound, the fan heater was out of reach and there was not going to be a further visitor until the carers morning round.

When the morning carers attended they found that the fan heater was still in the same position and that the room was extremely hot. Mrs Nesbitt was in the last stages of life, still in her bed. All proper measures were taken by the carers in calling for the Emergency Services etc., but Mrs Nesbitt could not be saved. The inquest found that the medical cause of death was hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema. In simple terms the overheating of the room, with Mrs Nesbitt’s inability to regulate her own body temperature through age and illness had taken her life. It was noted that her old age and frailty were contributing factors.

(1) It is accepted that the circumstances were unusual and none of the carers were likely to have been trained what to do in such a situation. Indeed, it is accepted that they were placed in a difficult position, not turning the heater up would lead to the client being cold during the night, turning it up with no one due in to review the situation led to an uncomfortable and ultimately fatal situation for Mrs Nesbitt.

(2) Nonetheless, it is difficult to say that this would be a completely unique situation and it is not impossible that other carers will be faced with similar situations in the future. What is a carer supposed to do in that situation? One supposes that the only potential remedy might be to include the circumstances of this case as a discussion in training of carers.