Coronial
NSWhome

Inquest into the death of Judith Ingham

Deceased

Judith Ann Ingham

Demographics

89y, female

Coroner

Decision ofDeputy State Coroner Hosking

Date of death

2022-09-21

Finding date

2026-03-10

Cause of death

Burn wounds and the consequences thereof

AI-generated summary

Judy Ingham, aged 89, suffered severe burns from excessively hot water while bathing in her apartment on 26 August 2022, dying 26 days later from burn wound complications. A licensed plumber failed to install a required temperature control device (TCD) when replacing her hot water system on 19 April 2022. Regulations mandate hot water delivery at bathtubs not exceed 50°C; without a TCD, her system delivered water at 70°C. The coroner found systemic failures in plumber compliance, lack of mandatory professional development requirements, and absence of data collection on hot water system installations. Key lessons: ensure temperature control devices are installed on all hot water system replacements; implement mandatory continuing professional development for licensed plumbers; establish certificate of compliance systems; improve regulatory oversight and notification procedures for incidents.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Error types

proceduralsystem

Clinical conditions

severe thermal burn injuriesburn wound complications

Contributing factors

  • Failure to install temperature control device on hot water system replacement
  • Hot water delivered at 70°C instead of required maximum 50°C
  • Lack of mandatory continuing professional development for plumbers
  • Systemic failure to comply with plumbing regulations by multiple contractors
  • Absence of data collection on hot water system installations
  • Inadequate regulatory oversight by Building Commission NSW
  • Failure to notify SafeWork NSW of incident or death
  • No certificate of compliance requirement for hot water system work

Coroner's recommendations

  1. SafeWork NSW should consider and investigate the omission of installation of a temperature control device on 19 April 2022 by Michael King of Hillier Plum Pty Ltd t/as Hillier Plumbing
  2. SafeWork NSW should consider and investigate the failure to notify or attempt to notify SafeWork NSW of the death of Judith Ann Ingham prior to 30 January 2026
  3. Building Commission NSW should give consideration to introducing a continuing professional development requirement as a condition of license renewal for plumbers in NSW
  4. Building Commission NSW should give consideration to requiring plumbers who install, replace, repair or alter a hot water system in NSW to complete a certificate of compliance that must be lodged with the Building Commission NSW within 7 days of completion of the works
  5. Building Commission NSW should give consideration to conducting an investigation pursuant to s 60 of the Home Building Act 1989 (NSW) into the omission of installation of a temperature control device on 19 April 2022
Full text
Official source Archived copy

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Source and disclaimer

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