The experience for 43 children treated inadvertently with a chemical pipe cleaner at a HSE dental clinic last October was “devastating”.
That is according to the HSE who yesterday apologised for the harm caused to the children and their families over the pipe cleaner, ‘Red Streak’, containing the Potassium Hydroxide 5%, contaminating water used to clean the mouths of children during dental procedures at the HSE-run Ennis Dental Clinic.
In a 37-page report on the incident over October 4 and October 5 last, the HSE found 15 of the 43 children exposed to the poisoned water suffered “adverse localised symptoms ranging from mild burning sensation to blistering and ulceration of the mouth”.
The report reveals a parent alerted clinic staff to an adverse reaction suffered by her daughter, but the ‘Red Streak’ source wasn’t identified for another four and a half hours and at least one other child had been exposed to the contaminated water during that time.
The HSE acknowledged the treatment experience of the children “may have a psychological effect on them and their families, and in their confidence in the dental service going forward”.
The HSE investigators were unable to identify the source of the bottle of Red Streak and could not establish when and by whom it was added to the water supplying the dental equipment.
The HSE investigators have, however, found internal security within the dental clinic was poor; domestic cleaning products were not stored securely; there was a lack of written standard procedures, and that staffing in the Central Sterile Services Room was not adequate to ensure safe work practices.
Head of primary care with HSE Mid West community healthcare, Kate Duggan said: “Our investigation as to how this happened is inconclusive but it is obvious to us that four incidental findings will now greatly reduce, if not eradicate, the possibility of this happening again.”
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