Inquest into the death of Judith Ingham

CORONERS COURT OF NEW SOUTH WALES Inquest: Judith Ann Ingham Hearing dates: 2-4 February 2026 Date of findings: 10 March 2026 Place of findings: Coroners Court, Lidcombe Findings of: Deputy State Coroner, Magistrate Hosking Catchwords: Requirements regarding the installation of temperature control devices; Notifications to SafeWork NSW; Building Commission oversight of licensed plumbers; continuing education of licensed plumbers.

File number: 2022/284211 Representation: Counsel assisting the inquest: Kate Holcombe of Counsel instructed by Elizabeth Blomfield, NSW Crown Solicitor’s Office (Assisting team) Building Commission NSW: Ahmed Rizk instructed by Tommy Kam, Department of Customer Service.

Hillier Plum Pty Ltd t/as Hillier Plumbing and Michael King: Alexandra Burkitt of Counsel instructed by Ryan Francis and Brandon Hoffler of Lander & Rogers.

Findings: Identity of deceased: Judith Ingham Date of death: 21 September 2022 Place of death: Royal North Shore Hospital, St Leonards,

NSW Manner of death: Judy suffered extensive burns in her bath 26 days prior to her death from excessively hot water in circumstances where the hot water system to her bathtub had been replaced on 19 April 2022 without a temperature control device being installed.

Cause of death: Burn wounds and the consequences thereof.

Recommendations: To SafeWork NSW That SafeWork NSW consider and/or investigate: (1) 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; and (2) the failure to notify or attempt to notify SafeWork NSW of the death of Judith Ann Ingham prior to 30 January 2026.

In accordance with s 82(4)(b) of the Coroners Act 2009 (NSW), I direct that a copy of the Brief of Evidence and exhibits tendered in this proceeding, and that the transcript of the hearing, be provided to SafeWork NSW.

To the Building Commissioner NSW (1) That the Building Commission NSW give consideration to introducing a continuing professional development requirement as a condition of license renewal for plumbers in

NSW.

(2) That the Building Commission NSW 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.

(3) That the Building Commission NSW 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.

Introduction 1 Judith Ann Ingram OA (Judy) was born on 21 January 1933. She was the loved mother of 9 and many of her children attended the inquest either in person or via AVL. Judy was also a loving grandmother of 16 and great grandmother of 10.

2 Twenty-six days before her death, Judy was burned by excessively hot water in her bath at her home. She sustained burns to 16% of her total body surface area. She was transported to RNSH1 where she received palliative care until her death.

3 These are the findings of an inquest into the circumstances of Judy’s death.

4 This inquest is held pursuant to s 21(1) of the Coroners Act 2009 (NSW) (the Act) in circumstances where Judy’s death was a reportable death as defined in ss 6(1)(a) and (c), being a death which was unnatural and in unusual circumstances.

The role of the coroner 5 The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death.2 A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future.3 The issues examined at the inquest 6 The inquest was held in the Coroners Court at Lidcombe between 2 and 4 February 2026.

1 Royal North Shore Hospital.

2 S 81 of the Act.

3 S 82 of the Act.

7 The issues identified in the coronial investigation to be explored in the inquest follow.

(1) The replacement of the hot water system on Level 6 of the premises at 20/18 Cranbrook Ave, Cremorne, NSW (the premises) on 19 April 2022, and in particular, the omission of installation of a temperature control device (TCD) on that date.

(2) Whether a notification to SafeWork NSW was made in relation to Judy's death.

(3) Whether a recommendation should be made pursuant to s 82(2)(b) of the Act that the following be investigated by SafeWork NSW:

(a) the omission of installation of a TCD on 19 April 2022

(b) any failure to notify SafeWork NSW of Judy's death.

(4) The regulatory oversight of plumbers by the Building Commission NSW (BCN)4 vis a vis the installation of TCDs, including the following matters:

(a) the adequacy of the ‘Plumbing Industry Technical Note 1/2013’

(TN 1/2013)

(b) the ongoing educational requirements of licensed plumbers.

(5) Whether a recommendation should be made pursuant to s 82(2)(b) of the Act that the omission of installation of a TCD on 19 April 2022 should be investigated or reviewed by the BCN.

8 As will be seen below, as the inquest progressed, some of these issues became less relevant and other issues arose.

4 Prior to 1 December 2023, the plumbing industry was regulated by NSW Fair Trading, now the role of the Building Commission.

The evidence 9 Tendered to the court was a 7-volume brief of evidence5 compiled by the NSW Police Force Officer in Charge of the coronial investigation, Constable Louis Barnes, and supplemented by the Assisting team. In addition, a bundle of documents received from Hillier Plumbing in the course of the inquest formed Exhibit 2.

10 Oral evidence was also taken from the following witnesses at the inquest: (1) Jess Fletcher, licensed plumber, former employee of Hillier Plumbing Pty Ltd, currently operates JF Plumbing Group (2) Michael King, licensed plumber, operational manager at Hillier Plumbing (3) Luke Hillier, licensed plumber, director of Hillier Plumbing (4) Greg Howard, director of Howard Plumbing Pty Ltd (5) Matthew Whitton, director, practitioner compliance, BCN (6) Tristan Luther, manager, building inspections, BCN.

Findings 11 Having considered all of the evidence and submissions in this inquest, my findings follow.

(1) The effect of the relevant legislative instruments is that newly installed hot water systems must keep water at or above 60°C to avoid the risk of legionella bacteria growth. However, the hot water which is delivered at a person’s sink, or basin, shower or bathtub, must not be greater than 50°C. To achieve this, hot water systems are required to have an 5 Exhibit 1.

‘approved’ TCD installed. The TCD is to blend the hot water with cold, to ensure delivery of not more than 50°C.

(2) When the hot water system to Judy’s apartment was replaced, a TCD was required to be installed by King and was not installed.

(3) The failure to install a TCD when replacing the hot water system meant that the water delivered at the hot water tap of Judy’s bath was delivered at 70°C, some 20°C higher than what is required by law, and that it was in this context that Judy, while taking a bath, was severely burnt.

(4) Judy died on 21 September 2022 at the RNSH from burn wounds and the consequences thereof.

(5) No notification to SafeWork NSW was made in relation to the circumstances surrounding Judy’s injuries or subsequent death.

Recommendations To SafeWork NSW 12 That SafeWork NSW consider and/or investigate: (1) 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; and (2) the failure to notify or attempt to notify SafeWork NSW of the death of Judith Ann Ingham prior to 30 January 2026.

In accordance with s 82(4)(b) of the Coroners Act 2009 (NSW), I direct that a copy of the Brief of Evidence and exhibits tendered in this proceeding, and that the transcript of the hearing, be provided to SafeWork NSW.

To the Building Commissioner NSW 13 That the Building Commission NSW give consideration to: (1) introducing a continuing professional development requirement as a condition of license renewal for plumbers in NSW.

(2) 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.

(3) 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.

Background 14 I have drawn from submissions by Counsel assisting in relation to noncontentious factual matters and issues. I am grateful for this assistance.

Judy 15 Judy worked as a pharmacist until she retired age 70. She was an artist who painted fine china. She was also a writer having self-published a book. She volunteered extensively and was an active member of her church community.

She received an Order of Australia in 2022 for services to both pharmacy and to the community.

16 Prior to her death, Judy lived independently on Level 6 of the premises.

Notwithstanding her age (she died 3 months before her 90th birthday), Judy remained an active member of her family and community right up until her death.

17 Judy’s medical history included: diagnosis of late onset epilepsy in 2015; aortic stenosis and a pacemaker that was inserted in 2011 for intermittent heart block and renal impairment.

18 As at August 2022, Judy was prescribed: Rivaroxaban 15mg; Bisoprolol 2.5mg; Keppra 250mg; Spironolactone 12.5mg; Frusemide 20-40mg and Vitamin D

1000IU.

19 Each level of the premises where Judy lived was serviced by a hot water system situated in the common laundry on each level.

20 On 18 April 2022, the hot water system on level 6 of the premises burst, partially flooding Judy’s apartment. While repairs were conducted, Judy moved to live with her daughter Rose.

21 On 19 April 2022, King of Hillier Plumbing replaced the burst hot water system, installing a Rheem hot water system. Relevantly, King did not install a temperature control valve or other TCD on the replacement hot water system on level 6. It was revealed in the coronial investigation that between 2019 and April 2022, Hillier Plumbing had also replaced the hot water systems on levels 1, 3, 5, 7, and 8 of the premises. TCDs were not installed on those levels or on levels 2 or 4 which were replaced by One Point Electrical and Goldman Plumbing respectively.

22 On 24 August 2022, Judy moved back into her apartment after the repairs had been completed.

23 On the morning of 26 August 2022, Judy ran herself a bath. Her family describe her as an avid bath lover, and someone who might have a bath up to 3 or 4 times a day.

24 At some point that morning, possibly around 11.30am, Judy knocked on the door to the apartment opposite hers, Unit 21, where her neighbours, Andrew and Kristen6 lived with their young son.

25 Andrew recalls that Judy told him she had been burned in the bath and asked him to help her drain the bath, but warned him not to put his hand in. Andrew used a spatula to knock the plug out of the bath.

26 Judy then lay on her bed on her side. Andrew sent Kristen to go and check on Judy. Kristen recalls that Judy said it was too sore to lie on her back.

27 Kristen then called Judy’s daughter Rose, before getting some cold compresses for Judy’s back. When Kristen lifted Judy’s jumper, she saw significant damage to the skin and, at 12.42pm, she called 000.

28 Kristen was told by the emergency operator to place Judy into a cold shower.

Judy told Kristen she had been in the bath ‘a while’. It is not clear precisely how Judy came to be burned in the bath. It was submitted that perhaps at some point she turned the hot water on to ‘top up’ the bath. While I am satisfied on the evidence that Judy’s burns were suffered in the bath, I am unable to make a finding as to precisely how that occurred7.

29 Rose and her daughter Eliza arrived at the apartment and helped Judy onto a chair in the shower.

30 In the meantime, Andrew had gone back to his apartment and recorded the temperature of the hot water from his kitchen sink with a meat thermometer. It showed a reading of 70°C.

31 At 1.02pm, NSW Ambulance paramedics arrived, assessed Judy and then conveyed her to RNSH. Judy’s prognosis was poor. Judy confirmed that she 6 Andrew and Kristen provided statements which are included in the brief of evidence. They were not required to give evidence.

7 Such a finding being available based on Judy’s reported conversation with her neighbours, Andrew and Kristen, Andrew’s statement as to removing the water from Judy’s bath with a spatula and the nature of Judy’s injuries being consistent with having been burned in the bath.

wanted the approach to her care to be primarily palliative with an intense focus on comfort. This was the approach adopted and on 21 September 2022, Judy died while still an inpatient at RNSH. Her family describe Judy as gaining strength and peace through her Catholic faith at this time, despite being in significant pain in her final weeks of life.

Post-mortem report 32 Dr Van Vuuren, forensic pathologist, undertook an external autopsy examination of Judy on 26 September 2022. Dr Van Vuuren opined that Judy’s death was caused by burn wounds and the consequences thereof.

33 On examination Dr Van Vuuren found burn wounds measuring 16% of Judy’s total body surface in the left axilla (armpit), the left upper back extending to the left buttock. She also found partially healed burn wounds on the right dorsal aspect of the back.

Rectification works 34 On 29 August 2022, Judy’s son Stephen, attended Judy’s apartment and took images and video recordings of the water. He recorded the temperature of the hot water to be 70°C.

35 On 30 August 2022, Fletcher was sent by his employer, Hillier Plumbing, to attend the apartment block and test the water temperature on all eight floors.

He was not told why he was given this task. He discovered that the temperature of the hot water system for level 6 was markedly higher than the other apartment levels (73°C, when checking the temperature at the laundry spoke (i.e. the location closest to the hot water system). He also noted that the thermostat had been turned to level 7 instead of level 3. Fletcher turned the thermostat down to 3. He had a conversation with either King or Hillier or both.

36 On 5 September 2022, Howard, of Howard Plumbing, was engaged to provide an independent review of whether the apartment block hot water systems required TCDs. Howard advised that TCDs were required. Between September and November 2022 Howard installed TCDs in all levels of the apartment block.

Plumbing requirements and regulations 37 The relevant regulating instruments include: (1) Plumbing and Drainage Act 2011 (NSW) (PD Act) (2) the Plumbing Code of Australia (PCA)8

(3) AS/NZS 3500.49.

38 In NSW: (1) all plumbing work must be performed by a licensed contractor, or someone supervised by a licensed contractor10 (2) the responsible person for plumbing and drainage work must ensure that the work complies with the PCA11 (3) the ‘design, construction, installation, replacement, repair, alteration and maintenance of a heated water service must be in accordance with

AS/NZS 3500.4’12 (4) heated water services must store water at a temperature of not less than 60°C (as a legionella control measure)13 8 Found within Volume 3 of the National Construction Code, at the time of Judy’s death, the 2019 version was in force.

9 AS/NZS 3500 is the Joint Australian and New Zealand Standard, prepared by the Joint Technical Committee, plumbing and drainage.

10 Section 6, PD Act.

11 Section 7, PD Act.

12 B2.9 PCA.

13 PCA B2.8 and 1.11.1 AS/NZS 3500.4.

(5) ordinarily14 the delivery temperature of heated water at the outlet of each sanitary fixture15 must be not more than 50°C16 which must be achieved in accordance with AS/NZS 3500.417 (6) the types of TCDs which can be installed to deliver heated water to the 50°C limit must be either a thermostatic mixing valve, a thermostatically controlled tap, a tempering valve or a temperature limited water heater.18 39 I find that the effect of the relevant legislative instruments is that newly installed hot water systems must keep water at or above 60°C to avoid the risk of legionella bacteria growth. However, the hot water which is delivered at a person’s sink, or basin, shower or bathtub, must not be greater than 50°C. In order to achieve this, hot water systems are required to have an ‘approved’ TCD installed. The TCD is to blend the hot water with cold, to ensure delivery of not more than 50°C.

The role of the Building Commission NSW 40 Luther and Whitton of the BCN provided a joint report and gave evidence concurrently at the inquest.

Publications 41 The BCN19 issues industry based publications to alert tradespersons to policy and legislative changes. An example relevant to this inquest, is TN 1/2013.20 42 To assist plumbers in understanding when TCDs are required to be installed, NSWFT published21 TN 1/2013 containing a chart describing various scenarios 14 Different requirements apply for residential aged care, health care, accessible facilities and educational facilities – none of the relevant exceptions apply to this case.

15 That is, a shower, bath, hand basin as opposed to a kitchen or laundry outlet.

16 B2.5, PCA and Clause 1.11.2, AS/NZS 3500.4.

17 B2.6, PCA.

18 B2.6, PCA.

19 Previously NSW Fair Trading (NSWFT) in its capacity as regulator.

20 This was updated in May 2021, which remains the current version. It was accessed via the ‘MyServiceNSW website on 5 February 2026: https://www.nsw.gov.au/housing-and-construction/compliance-and-regulation/plumbers-anddrainers/standards-and-notes 21 Initially on the then Department of Fair-Trading Website.

and whether a temperature control device is required to be installed (see [60(2)].

43 In addition to its web based publication: (1) a link to TN 1/2013 was sent by NSWFT to building industry professionals via its e-newsletter, Foundations on 4 September 2013 (2) a link to TN 1/2013 was sent by NSWFT via its e-newsletter, NewsFlush on 14 March 2018 – this publication is sent to all holders of endorsed contractors licenses, supervisors’ certificate or tradespersons certificate (unless they have ‘unsubscribed’) (3) a link to TN 1/2013 was sent by the BCN via its e-newsletter, Building Commission Plumbing News, to all then current subscribers to the former NSWFT newsletter, Newsflush, on 24 April 2024.

44 From June 2022 all relevant changes to legislation, the PCA or Australian Standards are communicated to holders of endorsed contractors’ licenses, supervisors’ certificate or tradespersons certificate (unless they have ‘unsubscribed’). E-newsletters are circulated more broadly to subscribers within the wider industry.

45 While the approach taken is potentially broad reaching, there is no system in place to ensure that the publications are being accessed and read.

Furthermore, the ability to unsubscribe means that significant industry updates may not be received by those who need them.

46 Luther and Whitton confirmed that there is presently no continuing professional development (CPD) in place for plumbers, drainers and gas fitters in NSW.

47 In 2024, the BCN partnered with Tafe NSW to deliver an online learning module for plumbers, drainers and gasfitters to understand their regulatory obligations in NSW. The course content includes detailing the PCA requirements for temperature delivery and control for heated water.

48 Online learning modules can have inbuilt systems requiring electronic feedback confirming the module has been undertaken. This avoids the present situation where updates (such as TN 1/2013) are part of an ‘opt out’ system and even for those remaining on the circulation lists, can be overlooked, deleted or unread.

49 An obligation to undertake CPD can be imposed by the BCN as a licensing condition (as is the case with builders). No such conditions are presently in place for plumbers.

The Building Commission NSW’s compliance and disciplinary role 50 Luther and Whitton outlined that the BCN has the power to inspect any plumbing work undertaken by licensed plumbers in NSW in accordance with the PD Act. There is currently no process for the collection of data in relation to the installation of hot water systems in NSW. Inspections that do occur are as a result of consumer complaints or data provided by other agencies.

51 The BCN is empowered by the Home Building Act 1989 (NSW) to take disciplinary action against a licensed plumber for non-compliance with legislative obligations.

Issues 52 The date, place, manner and cause of Judy’s death is not contentious. Judy died on 21 September 2022 at the RNSH from burn wounds and the consequences thereof.

53 The issues traversed in the inquest relate to the circumstances (manner) in which Judy died.

54 While I have had regard to all of the evidence and submissions in this inquest, I refer only to the salient aspects below.

The replacement of the hot water system 55 Pursuant to the relevant regulatory regime, the hot water which is delivered at a person’s sink, or basin, shower or bathtub, must not be greater than 50°C. In order to achieve this, hot water systems are required to have an ‘approved’ TCD installed. The TCD is to blend the hot water with cold, to ensure delivery of not more than 50°C.

56 It was not in contention in the inquest that when the hot water system to Judy’s apartment was replaced, no TCD was installed.

58 Evidence from Howard, Luther and Whitton was all consistent that a TCD was required in an installation of this nature.

69 Provision is made in the WH&S Act for the notification (by a person conducting a business) of incidents involving death or serious injury arising out of the conduct of the business.25 Section 38 WH&S Act provides: A person who conducts a business or undertaking must ensure that the regulator is notified immediately after becoming aware that a notifiable incident arising out of the conduct of the business or undertaking has occurred.

70 Consistent with s 81(3) of the Act, I do not suggest that any person has committed an offence under the WH&S Act or any other offence.

71 However, taking into account the following matters: (1) the potential that the investigative scope of SafeWork NSW would include an incident in the nature of the circumstances of Judy’s injuries and death; (2) the implications in terms of public safety given the severity of the consequences as seen by Judy’s injuries and death; and (3) the evidence that suggests the failure to install TCDs is potentially systemic and not just ‘one off’,26 I consider it is necessary and desirable that the recommendation below is made. I note that no submissions were received opposing this recommendation.

25 Section 38 WH&S Act.

26 See [21].

75 Whitton gave evidence that: (1) upskilling the plumbing industry is a key strategic objective of the BCN (2) in the learning module that has been developed by the BCN in partnership with Tafe NSW, they have deliberately included an assessment component to provide ‘security’ and to ensure that participants were learning the information and actually taking it in. This learning module is being used not just by plumbers in training, but as a disciplinary/enforcement tool for plumbers otherwise identified as ‘noncompliant’.

76 It was of significant concern that not only had Hillier Plumbing failed to install TCDs at the premises, One Point Electrical also failed to install one on level 2 on 3 February 2018 and Goldman Plumbing had failed to install one on level 4 on 24 July 2014. All of these installations followed the release and publication of TN 1/2013. This is indicative of a systemic failure to comply with regulations notwithstanding the material disseminated by the BCN. In the circumstances, I consider it necessary and desirable to make Recommendation 1 below with a view to the provision of educational support to NSW plumbers.

Regulation of the installation of hot water systems 77 Luther and Whitton gave evidence regarding the BCN’s work in the space of data collection to improve both education, information provision to plumbers and consumers and enforcement action.

78 At present, there is no data collection capturing the installation of hot water systems in NSW. If such data were available, there would be capacity for the BCN to ascertain compliance with the relevant legislative regime via inspections/spot checks of installed services.

79 A requirement that a template certificate is to be lodged with the BCN following the installation of a hot water system would allow for the capturing by the BCN of a baseline to gather appropriate data to assist in regulation. It would also, potentially, require the installer to turn their mind to the legislative regime which they are certifying they have complied with as part of the installation process.

80 Recommendation 2 below seeks to address this issue and provide for the collection of data to the BCN to provide an appropriate baseline for review and regulation.

81 Judy’s death highlights the gravity of the consequences to a vulnerable woman of the failure to install a TCD.

82 Positively: (1) Hillier Plumbing provided the court with a number of examples since the incident where Hillier Plumbing have identified the need for the installation of TCDs on hot water systems. They also ‘introduced’ during the inquest a mandatory form to be included in all ‘hot water jobs’ prompting a technician to specifically consider whether a TCD is required.

83 Notwithstanding those positive steps, I consider that an investigation by the BCN remains appropriate in circumstances where: (3) Neither Hillier nor King were aware that they are nominated supervisors for Hillier Plumbing or what such a role entails.

84 It is for these reasons that I make recommendation 3 to the BCN.

89 I thank the officer in charge, Constable Louis Barnes, for his work in conducting the investigation and compiling the brief of evidence which was supplemented by the Assisting team.

Statutory findings required by s 81(1) 90 As a result of considering all the documentary and the oral evidence heard at the inquest, I make the following findings: Identity The person who has died is Judith Ann Ingham (Judy).

Place of death Judy died at the Royal North Shore Hospital, St Leonards, NSW.

Date of death Judy died on 21 September 2022.

Manner of death Judy suffered extensive burns in her bath 26 days prior to her death from excessively hot water in circumstances where the hot water system to her bathtub had been replaced on 19 April 2022 without a temperature control device being installed.

Cause of death Judy died from burn wounds and the consequences thereof.

I close this inquest.

Magistrate R Hosking Deputy State Coroner Lidcombe **********