Jan Mary Courter was taken to Flinders Medical Centre in Adelaide in February 2008. The 56-year-old was suffering from a number of illnesses, including alcoholic liver disease, and needed assistance to move.

A week after she entered hospital, a nurse took Ms Proctor to the shower and put her in a shower chair. The nurse left the bathroom and returned 10 minutes later, by which time the room was filled with steam.

Counsel assisting the Coroner Naomi Kereru, said: “Ms Proctor was slumped in the shower chair and her skin was noted to be peeling from her chest and stomach.”

The patient was transferred to the burns unit at the Royal Adelaide Hospital with burns to 75 per cent of her body.

Ms Kereru told the court that the shower temperature could reach up to 60C. While there was a thermostatic regulator and an emergency alarm, it does not seem they were working.

Ms Proctor went into septic shock and later died from organ failure.

Ms Kereru said: “(There is a question as to) whether it was appropriate for Ms Proctor to be left in the shower on a chair for the period that she was.”

Ms Proctor’ sister, Karen Fitzgerald, said that the patient’s immobility may also have been an issue.

“My view was that if something had gone wrong when she was in the shower chair, I don’t think she would’ve had the capacity to sort it out,” said Ms Fitzgerald.

“I wouldn’t have trusted her level of mobility…I wouldn’t have thought she could be unattended at all.”

The inquest continues.