Safety alert after patient deaths from ingesting cleaning gels

NHS Improvement has told all care settings including hospitals, mental health units, ambulance trusts, care homes and community services to adopt “strict restrictions” on the use of polymer gel products.

The warning has been issued as three patients have died after ingesting polymer gel granules and two more have required emergency treatment since 2017.

NHSI said superabsorbent polymer gel granules have remained in “routine use” across the health service for the containment of bodily waste, despite a previous patient safety alert.

In 2017, NHSI issued a patient safety alert warning of asphyxiation risks associated with the gels after a patient died ingesting a sachet of granules that had been left in a urine bottle in their room.

Since then, NHSI has identified another 12 incidents — of those, two patients died and two more needed emergency treatment.

These incidents involved polymer gel products being left in urine bottles or vomit bowls, NHS Improvement said.

The superabsorbent granules, including sachets, mats and loose powder, are used to reduce spillage on bedding, clothing and floors when patients use vomit bowls or urine bottles, or when fluid-filled containers, such as wash bowls or bedpans, are moved by staff.

The national patient safety alert said: “Reports described patients opening sachets and tipping the contents onto food or drink, eating the sachet itself or eating the activated or partially activated gel from urine bottles, drinking beakers, tea cups and plates of food.

“Many reports described confused or otherwise vulnerable patients given a dry urine bottle or vomit bowl with a sachet (or multiples) inside, or sachets left on or near patient tables or removed by patients from tables and trolleys.

“A particular risk are patients who are transferred with these products to areas unfamiliar with their use or that do not realise the patient has these with them, or where temporary or junior staff use the products as they have seen them used in other areas.”

The alert instructed all hospitals, mental health units, hospices and care homes to either exclude polymer gel products from all patient uses or restrict them to exceptional use only via a specialist team.

Ambulance trusts have been asked to ban polymer gel sachets, mats and loose powder or restrict their use to settings where patients are constantly observed. Community nursing and therapy services have also been told to ban polymer gels from patient uses or draw up risk assessments.

All care settings have been told to block unauthorised ordering of polymer gel granules and, if they still need the sachets, mats or loose powder, to buy the products patients are least likely to confuse with food and keep them secure and away from patients if they are for non-patient use.

NHSI is telling organisations to take this action by 1 June.

NHS Supply Chain said it will stop ordering the polymer gel products as described by NHSI. The procurement service has spent £185,770 on superabsorbent gels over the past 12 months across several products, including boxes of 100 7-7.5g sachets, along with 360g-475g shaker pots and 4kg-5kg buckets of loose powder.

Most of these products have been procured for hospitals and ambulance services, NHS Supply Chain said.

A supply chain spokeswoman said: “We are looking at alternatives that may come to market.”