An inquiry into the death of a disabled Calgary man heard disturbing details Monday.
David Holmes died in 2011, five weeks after suffering burns while being bathed at his group home.
The inquiry heard the 35-year-old man, disabled by seizures at a young age, was nonverbal and communicated by smiling and making gestures.
A caregiver testified she checked the water temperature, bathed and dressed David.
She said she later noticed skin peeling off of David’s buttocks and foot, and then alerted an on-call supervisor.
Another caregiver drove David to the hospital.
An advocacy group says someone needs to be held accountable.
“Everybody just wrings their hands and goes the other way,” said Ruth Adria, of the Elders Advocates of Alberta Society, outside of court.
“We say criminal charges need to be laid. We don’t say it’s too late,” said Adria.
Adria is outraged 9-1-1 wasn’t called, and police weren’t notified until after David died.
And she scoffs at the changes that have since been made, wondering how much training is needed to realize when water is hot.
“The one minister put up thousands of dollars and signs and temperature gauges. That is ridiculous,” she said.
The executive director of the not-for-profit agency which was caring for David hopes the inquiry will help prevent a tragedy like this from happening again.
“That is a mystery that haunts us. It really does,” said Joanne Hart Sweazey, Executive Director of Supported Lifestyles.
“And it’s hard to think about it yeah, especially because he (David) never did anything wrong to anybody. It’s not fair.”
The provincial government has since installed anti-scalding devices in care homes across Alberta, and staff are now required to take and record water temperatures.
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