A Saundersfoot nursing home patient with mental health problems, who suffered scalding in a bath, died from natural causes, an inquest decided on Monday.

But the Pembrokeshire Coroner Michael Howells said the death of Mr John Heywood Davies, aged 82, was aggravated by lack of care by person or persons unidentified at Brooklands Home.

A Health and Safety Executive principal inspector said after the inquest that a full investigation would now be made of all the evidence to decide whether any further action needed to be taken.

A special thermostatic mixing valve, which was supposed to ensure the water temperature did not exceed 43C, has been taken away.

The Coroner heard how Mr Davies, who suffered from dementia, epilepsy and heart and brain degenerative conditions, always became aggressive when bathed.

Around 7.15am on March 16th, because he was in a soiled state, the night carers bathed him. The three nurses were Lithuanian, Zulu South African and Indian and the coroner was told there were language difficulties, although two could speak reasonable English.

Nurse Patience Ngobu said her language was Zulu, Grazina Mostovojiene's was Russian and Martina Joseph's Hindi.

She said 'Jack' needed at least three carers to handle him because he struggled. Grazina, who ran the bath, told her she checked the temperature and it was ten minutes before Jack complained it was too hot.

Nurse Mostovojiene stated that no-one checked the thermometer on the bath.

Carer Louise Davies, of Hebron, said she heard a commotion in the bathroom and thought it was 'just Jack being Jack'.

But as Patience washed him, Grazina was throwing jugs of cold water on his legs which were 'red raw' from feet to thigh. As he was being dried he had a fit and his heart stopped.

HSE principal inspector Philip Charrett said there were problems with the tap when tested.

The coroner said: "It is quite difficult to ascertain exactly what happened because of the language difficulties," adding that he was satisfied there was want of care.