An 81-year-old MRSA sufferer died just weeks after he suffered a severe burn from a radiator in a nursing home.
He had been strapped into a chair and left beside the radiator while under sedation, the inquest was told.
Dr Myra Cullinane, the Cork Coroner, recorded a verdict of death by natural causes but recommended that patients who were confused and disabled should not be left next to an unguarded radiator.
Henry Pollard, of Rathvilly, Co Carlow, was left by a hot radiator inside the Avondale Nursing Home in Callan, Co Kilkenny, on the night and morning of May 23rd and May 24th, 2005.
He suffered a severe burn to his left arm - the damage was so severe that the outer layer of skin from his injured limb had stuck to the radiator and was found by a nurse.
Mr Pollard had drunk half a cup of tea with a crushed sleeping tablet or sedative suspended in the solution.
He would later die on July 8th, 2005, in Cork University Hospital minutes before he was due to be brought to the operating theatre to receive treatment for his infected wound.
Dr Cullinane yesterday explained that an inquest was called to examine the possible link between the burn sustained by the patient and his subsequent death.
Mr Pollard was an elderly Alzheimer's sufferer and had been placed in care by his family in the Avondale Nursing Home in Callan.
On the night of May 23rd and May 24th he was under the care of nurse Judy Delfin and care assistant Siobhan Browne. The court was told that there were two members of staff on duty caring for a full complement of 35 patients.
Ms Delfin, a registered nurse originally from the Philippines, described the scene that night. She told the court that Henry Pollard was her most difficult patient. "He was quite confused at times - it was quite difficult to give him medication because he would spit it out." She also claimed that Mr Pollard was prone to wandering around the hospital.
Ms Delfin said she feared that he would suffer an injury by falling out of his bed and so allowed him to sleep in what she termed a "Buxton chair". Following his dose of sedation, he was restrained in this chair by a "plastic strap". She moved him into the day room so that the television would keep him company. "At no time did I notice that he was in pain," she said. When the nurse returned to check on him at approximately 3am the care assistant, Ms Browne, noticed a wet or damp patch on his left arm.When the nurse inspected the area she noticed that the man had sustained a burn from a radiator. "It was quite swollen - I knew it was a burn," she said.
When asked by Dr Cullinane if Mr Pollard was able to move in the chair regardless of the strap, Ms Delfin replied: "I don't think so." The nurse washed the wound, dressed it, and alerted the next nurse on duty.
Since the incident, the radiator in the nursing home has been covered by a wooden cover.
The nurse claimed that Mr Pollard's daughter had insisted during a visit on the day of the incident that her father be placed against the radiator so that he could be kept warm.
Miriam Holmes, the director of the nursing home, said that during the day there were normally nine to 10 people on duty but that at night there were just two. She also said that patients were not routinely tested for MRSA at the home.
Following the incident, Mr Pollard was transferred to a nursing home in Cork.
The former matron at the home, Geraldine Harrison, who resigned from her post, said that Mr Pollard was a "very loveable man". Ms Harrison said the safety harness should not have been used by the staff. "I wasn't aware the harness was in use - it was not policy. Henry was a lovely man, very tall, very handsome," she added. "He should not have been placed by the radiator - he should have been in his bed."
Det Sgt Jim Lyng told the court that he had carried out a criminal investigation into the burning incident and sent a file to the Director of Public Prosecutions. The DPP advised that there would be no prosecution.
Dr Margaret Bolster told the inquest that her examination of the body revealed the man was suffering from MRSA and that both the wound and his respiratory system were infected by the disease. The man was also suffering from cancer and that Mr Pollard "could have died at any time".
However, she stressed that the burn and the resulting MRSA infection would not have helped his condition.
The infection would have tipped the balance.
"He may have survived longer if that [the MRSA] hadn't tipped the balance," she said.
Following the inquest, Mr Pollard's daughter, Ann Lane, was too distressed to comment.