Through its review of recorded patient safety events, the National Patient Safety Team identified issues relating to the ingestion of toilet gel discs.
An incident report described a small child who ingested a toilet gel disc. Hospital staff sought advice from Toxbase® (the online poisons information database) which stated the product was not toxic and therefore not thought to be of concern. The child was treated accordingly but sadly died a few days later.
The post-mortem showed erosion between the oesophagus and the aorta. It was thought the oesophageal ulceration was highly likely caused by the gel disc becoming lodged or stuck to the oesophagus (the product is intended to stick firmly to the toilet bowl), causing the erosion and fatal haemorrhage.
The team shared these findings with Toxbase®, the Royal Society for the Prevention of Accidents (RoSPA) and the Child Accident Prevention Trust (CAPT).
As a result, Toxbase® has been updated with a new warning recognising that whilst the product contents may be considered non-toxic on ingestion, it is possible that the disc may be lodged in a small child’s oesophagus, causing ulceration and harm without visible abnormalities in the mouth. RoSPA and CAPT also now include details of the risk in their advice to the public on household cleaning products.
These actions help improve clinical care and enhance understanding of this risk among clinical staff and the public.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.