A 72-year-old resident of Lomond Court Care Home in Glenrothes who had Alzheimer’s disease died of complications from aspiration pneumonia after eating chlorine tablets used as a disinfectant in the home.
The investigation found that a delivery of cleaning products, including the chlorine tablets, had been left in a corridor in an unsealed box. The tablets, which look like mints, had been eaten by the resident who was found distressed and in pain close to where the delivery had been left. Examination of the delivery by staff found that three of the 200 tablets delivered were missing.
The HSE investigation found that there had been no risk assessment of several chemical products used in the home, including the disinfectant tablets and that there was no safe system of work for the delivery of chemicals. The Inspector stated, “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.”
The care home was fined £270,000 after pleading guilty to breaching Section 3(1) and 33(1) (a) of the Health and Safety at Work Act.