William George KENT · Prevention of Future Deaths report

On January 23rd 2014 I commenced an investigation into the death of William George KENT, years of age. The investigation concluded at the end of the inquest on 23rd December 2013. The medical cause of death given was:

1a. Ischaemic heart disease
1b. Coronary artery atheroma, calcific aortic stenosis and chlorine inhalation
1c.

2. Infective exacerbation of chronic obstructive pulmonary disease

My narrative conclusion was: Whilst general frailty of health and ischaemic heart disease were likely to be co-factors it is clear that inhalation of chlorine was a significant contributing trigger which led to death

Mr Kent was admitted into St Peter’s Hospital Chertsey on 20th December 2012 after a fall at home. He was transferred to Ashford Hospital on 25th December 2012 for rehabilitation and management of his social circumstances and further treatment of his leg ulcers. At or around 0800 on 30th December 2012 a reasonably substantial quantity of ‘Haz-Tab’ granules was sprinkled on a large amount of urine on the floor next to Mr Kent’s bed and left for approximately ten minutes. This caused sore eyes and coughing for the person dispensing the granules. Shortly thereafter Mr Kent was seen to become acutely short of breath and in obvious respiratory distress. He was maximally treated at Ashford Hospital but there was no improvement in his condition and he was transferred to St Peter’s Hospital, Chertsey for further treatment. Unfortunately this was no successful and Mr Kent died at 20.16 on 30th January 2012.

1. Lack of awareness of the potentially harmful side-effects of Haz-Tab granules for urine spillages

2. Limited time given over to the teaching of the side-effects of cleaning products such as Haz-Tab granules at the induction of new staff and at yearly mandatory infection control updates

3. Lack of clarity on how Haz-Tab granules should be used in clinical spillages

4. An under-emphasis of the potential hazardous consequences from the release of noxious gases when Haz-Tab granules are in contact with urine (with or without contamination of blood)