An 81-year-old nursing home resident died after having a fit, shortly after being lowered into a hot bath that burnt his legs, an inquest has heard.
Home managers apologised to Mr Davies' family after the inquest
A post mortem examination could not determine exactly what caused John Davies' death at the Brooklands home near Saundersfoot, Pembrokeshire.
The inquest heard a carer had not checked the water temperature and his legs were left with blisters.
A verdict of natural causes, aggravated by lack of care was recorded.
Jugs of cold water were thrown over him, but he had a fit when he was returned to his bed and died, the court was told.
Pembrokeshire Coroner Michael Howells heard that night staff found that Mr Davies had soiled himself heavily just before 0700.
Mr Davies, who had dementia, epilespy and could not walk, could be aggressive, so three members of staff bathed him.
Carer Grazina Mostouojiene admitted in a statement to police that she ran the bath but did not check the water temperature.
Nurse Patience Ngobu told the inquest: "After 10 minutes of being in the bath, he said the water was too hot for him. I put my hand in the bath and I could feel it was hot."
Another carer Louise Davies, who was arriving for the day shift, described the scene in the bathroom.
"They were just filling up jug after jug (of cold water) and throwing it over his legs," she told the hearing.
"His legs from the bottom of his feet to the top of his thighs were red raw. There was blistering, skin peeling away from the legs."
Shortly after being returned to his bed, Mr Davies had a fit. Despite resuscitation attempts by staff and paramedics, who had been called, he died.
The home's deputy manager at the time, Michael Bridge, said he examined Mr Davies' body, which had "extensive blisters to his feet, redness to his legs and blistering to his buttocks".
He said after the examination, he contacted the Care Standards Inspectorate for Wales.
Mr Bridge said that the private home - which specialises in residents with dementia and mental health problems - had a policy for bathing residents and that a bath thermometer was tied to the bath.
He told the inquest there was a fail-safe measure in the tap that should have prevented water above 43 degrees centigrade passing into the bath.
But Philip Charrett, an inspector with the Health and Safety Executive (HSE) said when they examined the tap, they found it "could deliver temperatures much higher than 43 degrees".
A Home Office pathologist Dr D S Cook found that Mr Davies had second degree burns to his legs and buttocks, but said scarring was not deep enough to contribute directly to the death.
She said it was possible that it acted as a trigger to his fit but that he had significant natural disease, so the exact cause of death could not be ascertained.
The coroner said there may have been communication problems between the night staff - who were South African, Lithuanian and Indian - but he was satisfied that they were qualified and there was nothing to suggest that they were not competent.
Speaking after the inquest, Mr Bridge, who is now manager at the home, described Mr Davies as a "proper gentleman".
He said: "On behalf of all the staff and the owners of the home, we wish to express our deepest sympathy to Mr Davies' relatives and after 15 months we are glad to finally put this behind us."
He said that the three night staff no longer worked for the home.
Speaking for the HSE, Mr Charrett said in view of the coroner's findings, they would look again at the case and determine whether they would take any further action.