On 4 August 2015 a delivery of cleaning products was made to Lomond Court Care Home in Fife. These were left unattended in a corridor, in an unsealed box. In that box was a tub containing chlorine tablets which were unwrapped, about the size of a 10 pence piece, white and similar in appearance to mints.
Staff found 72-year-old James McConnell Fife (who suffered symptoms of Alzheimer’s Disease), distressed and in pain, close to where the cleaning products had been left. There was a white tablet on the floor next to him and at least one tablet in his mouth. The tub of chlorine tablets was lying open and three of the 200 tablets were missing. Mr McDonnell sustained an injury to his mouth and tongue as well as vomiting. As a result, he developed aspiration pneumonia, complications of which led to his death.
The HSE’s investigation found that prior to Mr McConnell’s death, the company had failed to assess the risk posed by several chemical products (including the chlorine tablets). They also failed to have an adequate system of work in place to manage deliveries of chemical products or to have an appropriate review procedure in place for the delivery arrangements of the chemical products for a period of two years.
Care home operator HC-ONE Limited of Southgate House, Archer Street, Darlington, County Durham, pleaded guilty to breaching Sections 3(1) and 33(1)(a) of the Health and Safety at Work Act 1974 and was fined £270,000.
Commenting, HSE Inspector Garry Miller said: “This distressing incident confirms the need for anyone handling potentially harmful substances to be extra vigilant in ensuring that they are not left unattended in circumstances where vulnerable people in their care can gain access to them.
“Suitable procedures need to be put in place and then regularly checked to ensure that they are being followed by everyone, not just for the use of such substances, but also for their delivery, storage and disposal.”
