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February 16, 2011

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Blind patient died after drinking toilet cleaner

An HSE inspector has criticised a Sheffield care home, claiming it had no excuse for failing to prevent elderly patients from being able to access dangerous chemicals.

Sheffield Magistrates’ Court heard that Derek Johnson, 80, died after inadvertently drinking toilet cleaner at Newfield Care Home on 20 July 2009. Mr Johnson, who was blind and suffered from dementia, had only been a resident at the home for a month prior to his death.

Mr Johnson began vomiting blue liquid and was taken to hospital, where he died just hours later. The liquid was later found to be toilet cleaner, which staff had seen in his room earlier that day but did not remove it.

The HSE’s investigation found that the home had inadequate procedures in place to prevent patients accessing dangerous chemicals. It discovered, for example, that trolleys containing hazardous liquids were often left unattended for considerable periods of time.

On 29 July 2009, the inspector issued three Improvement Notices to the home’s management company, Palms Row Health Care Ltd, which required it to carry out a risk assessment for the use of chemicals, prevent patients from being able to access dangerous items in the kitchen and laundry areas, and implement procedures to prevent access to chemicals.

HSE inspector, Carol Downes, revealed that, despite staff noticing that the toilet cleaner was in Mr Johnson’s room, they left him alone in the room for a number of hours. She said: “Mr Johnson’s death was a terribly tragic one, particularly as it could have been easily avoided by simply locking away the chemicals.

“There was no excuse for Palms Row Health Care’s failure to protect the vulnerable people in its care. It is imperative that care-home owners consider the risks to people they are looking after, and manage those risks to prevent incidents like this.”

Palms Row Health Care appeared in court on 15 February and pleaded guilty to breaching s3(1) of the HSWA 1974. It was fined £15,000 and ordered to pay £14,472 in costs.

In mitigation, the firm said it had no previous convictions and it fully cooperated with the HSE’s investigation. It has subsequently complied with the Improvement Notices by restricting access to the kitchen and laundry areas, and ensuring that chemicals were locked away after use.

Following the hearing, Mr Johnson’s brother Ray said he was still shocked by the manner of his death. He said: “Derek was placed in a nursing home for his own safety, and yet my very act of trying to keep him safe resulted in his death. I cannot reconcile this feeling and battle with it daily. I am still trying to come to terms with what I see as the untimely death of my big brother.

“We hope that lessons will be learned from what happened to Derek so that other families do not have to suffer the same heartache and loss that we are still suffering.”

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