Who’s Responsible for Preventing Scald Injuries? Part 1

I have served on many plumbing code and product standard committees and taught plumbing design and code review classes at various colleges and universities. I have also served on both model code interpretation committees. In addition, I have been writing for this magazine since 1994; many of my columns have been about hot water systems.

Over the years, this public exposure has led to many attorneys reading my columns or seeing my name on a code or standard committee. Consequently, I am frequently approached with requests to serve as an expert opinion witness or to undertake forensic investigations of incidents where many of the investigations are scald-related. 

These investigations routinely include inspections of plumbing, mechanical and fire protection systems; I provide reports of my findings or testify in depositions or trials, where necessary. In my work, I have found failures associated with a range of factors: system design, installation, product design, product manufacturing, facilities maintenance and system operation issues. These issues and failures frequently result in property damage, injuries and, in many cases, even death. 

My other plumbing and mechanical work includes investigations in the following areas: flood assessments and investigations; Legionella bacteria in building water systems; carbon monoxide leak incidents; fuel gas explosions and fires; plumbing/piping problems in tall buildings; product failures; and general system design, installation, maintenance and operation investigations.

Too many preventable scalding cases 

A disturbing trend I see is in the area of scald cases. I have encountered or noticed many unnecessary and preventable scald injuries or incidents where a lot of small children are scalded with extremely hot water, and the parents are immediately blamed. The agencies rarely seem to do a proper investigation into the faulty plumbing systems or any design, installation, code-compliance, maintenance or operational issues that often contribute to or cause the scald incidents. 

According to data collected by the National Electronic Disease Surveillance System and the National Inpatient Sample, two organizations that collected data on hospital patient injuries between 2016 to 2018, there were approximately 52,088 emergency room visits for tap-water scald injuries, 7,270 of which required hospital admission, and 110 deaths recorded in the United States. 

These tap-water scald burns to children account for about 17% of all childhood injuries requiring hospitalization. Often, the burns are severe, disabling and extremely painful; in many cases, the scald burns are deadly. Toddlers and preschool children are the most frequent victims, followed by the elderly and disabled. In 45% of the injuries to children, the child or a peer turned on the hot water. 

A disturbing statistic (which, from my experience, I find not to be truly representative) is that in 28% of all hot water scald cases recorded, the cause on the incident form was listed as “abuse” by the treating medical professionals or social workers. The attending agencies often look to blame the parents when a child is injured. The parent or guardian is hastily charged with a crime, and a significant number of these cases are prosecuted. 

I have investigated hundreds of scald cases, and a significant percentage of these involve children. In practically every case, the hospital contacts the local child and protective services (CPS) agency, in compliance with the protocol for children presented to the emergency room with suspicious injuries. 

I agree there needs to be an investigation into such cases. However, the investigation seems to always look at the parents and their background, and very little effort is spent looking into the building, the building owner, his background, his maintenance procedures, his compliance with the codes, etc. 

Parents or caregivers blamed for scald injuries

In one case, a mother whose 8-year-old daughter drew a bath and stepped in the bath without checking the temperature was startled, slipped, fell and hit her head on the edge of the tub, knocking her out in a tub of scalding hot water. A few minutes later, her mother found her lying face up in the tub with the water still running, the water was warm, not hot, by then. 

The mother reached into the tub to lift her daughter out, and the skin sloughed off her shoulders like a wet shopping bag. The child’s burn injuries were very traumatic to look at. The mother wrapped her daughter in a sheet and took her to the hospital emergency room, where she was directed to wait in a family waiting room. After a while, the mother was met by a CPS official and a sheriff’s deputy and they said: “We want you to take us to the scene of the crime so we can do an investigation.” 

It was at that moment the mother suddenly realized that they thought she had done this intentionally. In the medical reports, there were notes about bruises on her legs (they had a trampoline where the young girl had fallen on the springs and rails), and she had a big lump on the back of her head from when she fell into the bathtub. The burns were so severe the child was screaming and going into shock; the injuries upset the entire emergency department, the CPS workers and the sheriff’s deputy. 

The child was immediately sedated to ease the pain, but no one asked the child what happened. The mother was originally charged with child neglect, then a few days later, the child died from her burn injuries, and the charges were eventually changed to murder. The home was a rental home with a 20-gallon water heater that had the temperature turned up to 160 F, and there was a two-handle tub faucet with no maximum temperature-limit-stop adjustment. 

This was a very preventable injury/death. The mom was eventually cleared after a proper investigation was done to explain how there was a non-code-compliant plumbing system and that this was not an intentional act. 

In a southwestern state, a young man in his teens was babysitting for his aunt, who lived in a hotel converted into apartments. There was a copper fin-tube water heater with no storage tank and the system temperature was turned up extremely high to compensate for the significant temperature drop when there was peak hot water use. 

Copper fin-tube water heaters are unique in that when used for plumbing, they must have a storage tank and circulating pump, with the circulated distribution system connected to the tank and a separate circulated loop to go between the tank and the water heater. This is because they only raise the temperature about 35 F, plus or minus a few degrees, for each pass of water at a fixed flow rate through the heater. 

If the flow is too high, erosion will occur; if the flow is too low, scale will build up on the water side of the fin tubes. The system had the storage tank removed, and the hot water system had been altered and maintained by an unlicensed, untrained handyman. 

The system was dangerous, which led to the scald burn injuries to the child when he was bathing. The young man was charged with the crime of manslaughter when the child died of his injuries. Because the teen had a criminal record, it was easy for officials to blame the teen instead of investigating the dangerous, non-code-compliant plumbing system. 

In an East Coast city, a boyfriend with a criminal record babysat while the mom worked. The child was scalded in a bathtub. The boyfriend called the mom, and she came home from work to find the boyfriend applying burn medication on the child’s pinkish-red skin, only to see the skin sloughing off as he applied burn ointment. They called emergency medical services. 

Eventually, the couple were convicted of child abuse and murder for not seeking immediate medical attention. Yet, there was no investigation into the apartment’s hot water system that produced hot water in excess of 166 F. There was not a code-compliant shower valve in the apartment, and no human could react fast enough to get a child out of harm’s way when water at that temperature flows from the bathtub faucet. 

These are only a few examples of similar stories at colleges, condos, apartments and hotels, and in homes where poor or less fortunate people live in substandard housing conditions with plumbing systems that are not code-compliant, and fixing the condition would take a fraction of one month’s rent. 

We need to push for removing all the dangerous and deadly two-handle tub-shower valves and replace them with code-compliant shower valves where the limit stops are adjusted to supply a safe temperature. 

Hotel tub incidents

There are many hotel garden tub incidents. One involved a child who heard water running and climbed some steps up to a whirlpool bathtub filled with hot water while the parents were not nearby; the child was scalded to death.

Another scald incident occurred in a hotel chain in the mountains where a mother celebrating her anniversary rented a hotel room with a whirlpool tub and had a couple of glasses of wine while waiting for her husband to arrive after work. She turned on the water to fill the tub and waited to get in. 

When I recreated the incident, the hot water circulation pump was not working, and it took almost 4 minutes to get full-temperature hot water flowing into the whirlpool tub. The hotel’s hot water system produced hot water between 155 F to 160 F. So, when she started filling the tub and checked the water, it would have felt lukewarm; this was left over from prior hot water use. 

After the woman checked the water and went to have some wine, she then stepped into the whirlpool tub. The water temperature was about 145 F, and the tile work on the side of the tub was so wide that stepping over the edge and into the whirlpool tub was a commitment; it was difficult for me stepping into an empty tub. 

She began screaming in pain and disturbed other hotel guests, who called for security. When security arrived, they found the woman lying unconscious on the hallway floor with her bloody skin sloughed off her body; they also found large chunks of her skin floating in the bathtub, all over the carpet near the tub, and on the bed where she must have writhed and screamed in pain. The woman died from her injuries. 

This was a two-handled whirlpool tub faucet with no thermostatic temperature-limiting controls between the water heater and the whirlpool tub. 

A similar incident happened to a woman in a Midwest hotel and the attorneys for the defendant property owners fought back by attacking the victim, accusing her of drinking. She was in a hotel with a bottle of champagne waiting for her husband to arrive. There is no law against drinking in a private room, but there is a code/law requiring hot water flowing into a bathtub or whirlpool bathtub to be thermostatically limited to no more than 120 F. 

In all these cases, if the code had been enforced, none of these people would have been seriously injured or died. At 120 F, they would have had plenty of time to get out of harm’s way. 

What about the building’s water heating system?

When a child is injured or killed from a plumbing system tap water scald burn, I rarely see a full investigation into the building, the code conformance or the maintenance that is performed or not performed on the plumbing system. This includes the fixture, faucet type, temperature controls, system temperatures, temperature checks, etc., and all the things that may have contributed to the scald injury. It is crucial to see if the plumbing is code-compliant and whether the system was being maintained in a safe manner. 

Unfortunately, after a serious scald injury or death, I see a few photos of the child’s injuries and a whole lot of investigations into the parents and their backgrounds and criminal history. Sometimes, responding police or fire officials will take photos of the bathtub shower controls and check temperatures, and there may be a photo of the water heater. 

However, rarely is there an investigation into the building, the fixture where the incident occurred, the water heater and the plumbing system to determine if it was being maintained in a safe and code-compliant manner, or examining documentation to see who is responsible for maintaining the plumbing system. It is also rare to see any research into the code requirements for the subject building. 

Sometimes, there will be lots of photos of the water heater thermostat dial and follow-up reports blaming the parents for setting the thermostat to a very high temperature. In many cases, it is not until the experts hired by the attorneys do a site visit that the faucet type and the conditions of the system are known. These child protection agency personnel typically are not aware of what information needs to be gathered immediately after a scalding incident. 

I usually offer free seminars to CPS agencies requesting training, time permitting. CPS agency personnel must be taught that the water heater thermostat dial is not a hot water system temperature control. It is a burner control and not intended to sense or control the water heater outlet temperature. 

What should be done is to check if there is a code-compliant tub/shower valve with a maximum temperature-limit-stop that should have been adjusted to limit the maximum hot water temperature flowing into the tub/shower. The old two-handle fixtures cannot control pressure disturbances, which lead to thermal shock and scalding, and they cannot limit the maximum hot water temperature that can lead to scald injuries. 

All two-handle tub/shower valves that do not compensate for changes in pressure or temperature are not code-compliant. They are dangerous and should be removed. All model plumbing codes require ASSE 1016 pressure-balancing, combination pressure-balancing or thermostatic-type valves (or temperature-actuated mixing valves) on the water heater outlet to provide a thermostatically controlled safe and stable mixed hot water temperature to all fixtures in a residence. 

Child protection and police agencies should be trained in these types of systems and check to see if the plumbing systems meet code or not. However, a lot of time and resources are focused on checking the background and criminal history of the parents or guardians.

Too quick to place blame

The siblings and the injured child are often taken away from the parents while still grieving for the injuries or death of their child. Then they face scrutiny from officials and the public with questions such as: “Why didn’t you watch your child closer?” Most people do not realize that it takes 0.9 seconds for an adult male to get a third-degree, full-thickness scald injury at 150 F, and it only takes 0.5 seconds for a child to get a third-degree, full-thickness scald injury at 150 F. 

To put this into perspective, 0.5 seconds is about how long it takes to snap your fingers; that would not be enough time to sense a sudden change in temperature, react by screaming and then have someone respond and pull a child out of harm’s way. This is why we have code-compliant shower and tub/shower valves with pressure balancing, thermostatic or combination pressure-balancing, thermostatic controls and a maximum temperature limit stop adjustable to any temperature.

Plumbing codes require a maximum of 120 F, which gives adult males 4.8 minutes to get out of harm’s way before a second-degree blistering burn occurs. At that temperature, children have 1.2 minutes or 72 seconds before a second-degree blistering burn will occur. The product standard committees and code committees I have served on over the years all agree that 120 F is the maximum safe hot water temperature to allow someone adequate time to get out of harm’s way before a full-thickness burn injury occurs. 

You can also adjust your shower valve’s maximum temperature limit to 110 F and not worry about scalding because, according to the Moritz and Henriques burn studies, it takes 3.6 hours to develop a second-degree partial-thickness burn injury at 110 F. Most storage-type residential water heaters are not capable of providing 120 F hot water for that long of time. 

 The chart above is based on burn studies conducted by Drs. Moritz and Henriques at Harvard Medical College many years ago. This chart illustrates the time it takes for an adult and a child to receive first- and second-degree burns.

After hundreds of scald investigations, I can safely say that all scald burns are 100% preventable. With properly designed, installed, adjusted, maintained and monitored temperature controls, a hot water system can be safe. 

Next time, we’ll discuss preventative maintenance on hot water systems and hot water temperature limits in the plumbing codes.