Hudgell Solicitors has welcomed a national review over the safety of hand sanitisers on hospital wards following the death of an elderly patient at Hull Royal Infirmary who became confused and drank a full bottle.
John Haughey, 76, consumed the equivalent of a litre gin when drinking the 75% alcohol gel from the bottom of his hospital bed.
Following a legal case led by Hudgell Solicitors, Hull and East Yorkshire Hospitals NHS Trust recently admitted breach of its duty of care and agreed an undisclosed damages settlement with his family, having not disputed being liable for Mr Haughey’s death.
The incident sparked a national safety alert as Hull Coroner Prof Paul Marks wrote to NHS England highlighting his concerns that more deaths could be caused if changes are not made on hospital wards and lessons learned.
As a result, redesigns of bottles to limit the amount they dispense, and new protocols for medical professionals to follow should similar incidents happen, are now being considered.
Legal case highlighted failure to properly monitor patient after incident
The legal investigation into the matter highlighted how staff at Hull Royal Infirmary failed to act appropriately in the wake of the incident, errors which contributed to Mr Haughey failing to recover and dying a few days later.
At an inquest, evidence was heard from a pathologist who said Mr Haughey’s death of bronchopneumonia was ‘highly significant’ and that there had been a direct link between consumption of such a high percentage of alcohol and pneumonia.
The coroner concluded that inadequate observations had been made of Mr Haughey as he fell into a coma, as medical staff failed to record observations under the Glasgow Coma Scale, which would have given them a clearer indication of his state of consciousness.
These errors contributed to his airways being left ‘unprotected and vulnerable’ for seven hours, the coroner concluded.
Various medical professionals gave evidence to say that earlier steps should have been taken to support Mr Haughey’s breathing.
Solicitor Michelle Tebbutt says lessons must be learned around safety and medical response
Solicitor Michelle Tebbutt, of Hudgell Solicitors, represented Mr Haughey’s family and says that no matter what comes of the debate around the use and storage of gels on patient wards, there was a clear failing of staff at Hull Royal Infirmary to act appropriately.
She said: “This is a truly tragic case which has highlighted many areas of concern with regards to safety on hospital wards of confused patients.
“There is obviously a matter of significant national interest with regards to the appropriate use of sanitiser gels and their availability to vulnerable patients, and it would of course be very disappointing should we now see any more avoidable deaths in similar circumstances given the comments made by the coroner.
“Sadly, this case also highlights shockingly poor care provided to a vulnerable patient at Hull Royal Infirmary.
“Mr Haughey had consumed the equivalent to a litre of gin, and it was therefore only safe to assume the worst. Independent medical experts told the inquest into his death that it should have been assumed that he could become unconscious within the next hour or two, at which time there would have been a risk of aspiration.
“His treatment should therefore have been supportive and active in terms of ventilation to protect his airway. The observations made were simply not satisfactory and left him in great danger.
“He was unresponsive for close to seven hours before becoming completely unconscious, by which time his airway was in jeopardy. There was a risk of aspiration at all times, it was inevitable that he would become unconscious and not to take immediate action was a serious failing in care.”
Family upset by hospital’s errors and lack of information and compassion
Mr Haughey’s daughter, Diane Atkin, criticised the Trust for not only its failings in looking after her father, but also its treatment of her family in the wake of his death.
She says they were ‘economical and not forthcoming with the truth’ until the inquest was held and legal action launched through Hudgell Solicitors.
“It has been a disgrace from start to finish we were kept in the dark with very little information by the Trust over what had happened to my father, how it had ever been allowed to happen and the failings in treatment after he had swallowed the gel,” she said.
“First of all there were obvious questions over the hand gel, something we know has now become a national issue thanks to the support of the coroner. The top was so easy to unscrew and so easily accessible that it was an accident waiting to happen.
“What hurt us more though was the fact that we were shown no respect as a family and my father suffered from such poor care. He went into hospital for his safety, rapidly went downhill and never came out. When the incident happened we didn’t learn about it until four hours later. They then just left him in a room and didn’t monitor or support him as they should.
“Even when he was dying and we went in to say our goodbyes a nurse told us we couldn’t all be by his bedside at once. There was very little compassion.
“We asked questions afterwards but never got answers. It was only when we had the inquest that the NHS were forced to answer questions by the coroner and we started to find out what went wrong. Before that we just hit a brick wall and I think it is disgraceful for families who lose loved ones due to the negligence of hospitals to be treated in this way.”
Ms Atkin says her father, who had lived independently before being admitted to hospital, had become unwell with what was believed to have been a chest infection, and despite often being forgetful or confused, had not been diagnosed with dementia.
She says he told her he ‘felt safe’ when leaving him at hospital, but when she visited him the next day he was ‘completely different and totally confused’.
Just days after being admitted, she said he ‘didn’t know what he was doing’ and was not eating his meals.
It was on his fifth day in hospital that Mr Haughey drank a 535ml bottle of Purell hand sanitizer from the bottom of his hospital bed. This took his blood alcohol levels to between 35-40 units, but despite this, no immediate action was taken by medical teams to assist his breathing.
A serious incident report compiled by the Trust detailed how Mr Haughey had to be restrained by medical and security staff after drinking the gel so that he could be injected with a sedative, as he became ‘agitated and violent’.
By the time Ms Atkin was called and attended at hospital some hours later, she says her father was ‘seriously ill’, unconscious, and ‘covered in bruises’.
“I couldn’t believe how he looked when I got to hospital,” she said.
“He was unconscious and had severe bruising. He had bruising on his chest like somebody had sat on him and bruising to his wrists. We were simply told at the time that he had been restrained to calm him, but I was not happy to see him bruised the way he was.
“Then, I heard evidence at the inquest from a social worker that one of the nurses had been aggressive towards my father two days later when he was in intensive care and had regained consciousness.
“It was alleged the nurse said that we’d told her my father ‘was not a nice man’, so that he would hear it, and that she pulled part of his mask that was there to help his breathing away from him. It was alleged she also grabbed at his arm and she was also overheard saying ‘I’ve had to come out of the room before I hit him’ as she came out of the intensive care room.
“It was totally heart-breaking to hear and to think my father was put through all of this. In the end we did get an apology from the Trust, but it wasn’t sincere. If they had been sincerely sorry they would have been open and honest from the start about everything that happened.
“They throw apologies around like confetti when facing legal actions, but that is no comfort to families who lose loved ones. We were made to feel in the way and a nuisance as my dad was dying.
“It seems to me that there is a vast difference between the standards of care and that the elderly are not properly cared for. I saw elderly people wandering around and being left for hours without any one-to-one interaction. They leave the food and water with them and that’s it.
“More recently, my son needed emergency treatment for appendicitis at Hull Royal Infirmary and they were absolutely wonderful. They could not have done more and it was like being at a private hospital. Questions have to be asked about the standards of elderly care and the differences between wards. It is not acceptable.”
Safety of hand gels in hospitals has become a national issue
Since Mr Haughey’s death, coroner Prof Paul Marks has contacted NHS England in a bid to prevent future deaths. He also wrote to The Royal Society for the Prevention of Accidents; The Health and Safety Executive (HSE), Nuffield Health; BMI Healthcare and the Spire Healthcare Group.
As a result, NHS England’s medical director, Sir Bruce Keogh, has responded to highlight how latest NHS guidance stresses the need for detailed risk assessments of where gels are placed in relation to vulnerable patients.
He added that NHS Improvement is also exploring designs which could limit the amount of alcohol gel released from dispensers, and proposing to gather information to help develop standardised care procedures for situations where patients accidentally swallow such gels.