Care home resident waited three hours for ambulance after swallowing bleach tablets
A care home resident who died after eating bleach tablets that looked like mints waited more than three hours for an ambulance to take him to hospital, an inquest has heard.
Diabetic dementia patient Joe Serginson, 85, grabbed a tub from a cleaners’ trolley and swallowed the dissoluble disinfectant as staff dealt with a mess.
A senior carer told the inquest how she screamed and forced her fingers into his mouth to try to retrieve the chlorine tablets before dialling 999.
The incident happened at about 2pm on August 1 last year.
Staff called five times for an ambulance and a series of crews were tasked to attend Balmoral Court home in Byker, Newcastle, but were diverted to other cases.
It was only at 5.12pm, after the fifth call to the North East Ambulance Service (NEAS), that a crew attended and he was taken to the city’s Royal Victoria Infirmary, arriving just before 6pm.
Medics decided the prognosis was too bad for Mr Serginson to recover from the effects of the corrosive chemical and he was kept comfortable in hospital before he died on August 4.
Pathologist Peter Cooper carried out a post-mortem examination and concluded Mr Serginson died from respiratory failure having ingested chlorine tablets.
Newcastle assistant coroner Karin Welsh was told how the ambulance service had reached the stage of “clinical escalation” earlier that day, meaning there were too many jobs for the crews available.
NEAS complaints investigator Ruth Jackson told the hearing the situation happened on a daily basis and that it was to be addressed by more staff being recruited.
Cleaner Jamie Forbes said she had got her trolley out of a locked cupboard to tidy a mess in a corridor and the tub of chlorine tablets was on its top shelf.
They were round and white, and looked like extra strong mints, she said.
There were about 16 male residents staying on the top floor of the home, the inquest heard, and staff knew to keep an eye on Mr Serginson, who would go into other people’s rooms to pinch chocolates despite his diabetes.
Senior carer Jennifer Bolam said she was cleaning mess from a dado rail when she spotted him with the tub.
“It was so fast, he had put his hand in the jar, grabbed the tablets and put them in his mouth,” she said. “I screamed ‘Joe’ and grabbed hold of him.
“He was chewing so fast, that’s what made me think I have to put my hand into his mouth to get them out.”
She said other staff members raced to the scene to help after she screamed.
Mrs Bolam said they were advised to give Mr Serginson nil by mouth when they made the 999 call.
The staff member said colleagues discussed the case afterwards and all expressed surprise he could have removed the lid of the tub.
She said Mr Serginson would often say he was hungry and would pick up items and try to eat them.
A specialist in acute medicine said the delay in the ambulance attending did not make any difference to Mr Serginson’s chances of survival.
He would have aspirated matter into his lungs very shortly after eating the tablets and once that started there was little to be done for a frail patient, Dr Christopher Gibbons said.
But he said it could have made a difference to someone fitter than the pensioner.
The coroner said she looked at two issues – the delayed ambulance and the fact Mr Serginson could get hold of the tablets.
She said the 999 call handler initially graded the incident as requiring an ambulance within 30 minutes, but there was an understanding at the home that the crew could be delayed by more urgent patients.
Ms Welsh said in a second call a nurse at the home appeared to say an ambulance was needed more urgently before agreeing she could care for Mr Serginson while they waited.
The coroner also ruled the chlorine tablets should not have been on the trolley and the assumption dementia patients could not open a child-proof lid was “naive”.
She heard from Louise Spoors, new regional manager for the home’s owner Crown Care, which said the group no longer used the tablets and had brought in trolleys with lockable cupboards.
In a narrative conclusion, the coroner ruled: “Joe died as a result of ingestion of chlorine tablets not stored securely.”
She passed on her condolences to Mr Serginson’s wife of nearly 60 years, Maureen.
The widow replied saying the inquest had made things a little easier and added: “It may safeguard somebody else.”
Care home staff ‘did all they could’
The care home where a resident swallowed chlorine tablets has said staff did all they could to help.
In a statement after the inquest in Newcastle, owners Crown Care said: “Our staff were deeply shocked and saddened by the tragic accident which led to Joe Serginson’s death and we once again express our deepest condolences to his family.
“Those on duty faced a very difficult situation and did everything they could to help.”
It said extra training has been put in place and procedures have been reviewed.
It added: “We pride ourselves on providing a comfortable, safe environment with the highest standards of care for all our residents and the circumstances of this tragic incident were devastating for all those involved.”
Michael Scobie, the medical negligence lawyer at Irwin Mitchell who represented the family, said: “Crown Care now needs to ensure it learns from its mistakes and we have heard how they have implemented large scale changes in light of Joe’s death.
“We hope that what happened to Joe will ultimately protect other vulnerable residents of Crown Care’s nursing homes.”
After the hearing Mr Serginson’s 82-year-old widow said: “It has been difficult to hear the findings of the inquest and ultimately how Joe’s death perhaps could and should have been prevented.
“My only hope now is that lessons have been learned which will ensure that an incident like this never happens again.”
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