THE EXPERIENCE OF 43 children inadvertently treated with a chemical pipe cleaner at a HSE dental clinic last October was “devastating”, according to a HSE report.
The organisation has apologised for the harm caused to the children and their families after a pipe cleaner called Red Streak, which contains 5% potassium hydroxide, contaminated water that was used to clean the children’s mouths during dental procedures at the HSE-run Ennis Dental Clinic.
In a 37-page report about the incident, which occurred on 4 and 5 October last, the HSE notes that 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 that 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 was exposed to the contaminated water during that time.
The HSE acknowledged that 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”.
Outlining the chronology of the incident, the report states that at 10am on 5 October a dentist at the clinic remarked that a child’s “bubbly and spongy” gums were “nothing like I have ever seen before” after the child was treated with the contaminated water.
Thirty minutes later, at 10.30am, a parent of a child adversely affected by Red Streak the previous day arrived at the clinic to alert staff of the adverse reaction her child had suffered.
The mother told clinic employees that her child’s mouth was burnt, very red and sore. A staff member then attempted to make contact with the dentist who treated the child. The dentist was working at another clinic and was too busy to take the call.
More efforts were made to contact the dentist, who didn’t return the call until 3pm.
As a result of the call and questions asked by the dentist over the water in the dental cart, a dental colleague tasted the solution at the tip of the tongue “and it tasted bitter and had a burning sensation”.
However, before the dentist had returned the call at 3pm, another child was treated with the Red Streak-based solution during a procedure at 2.30pm. This procedure was abandoned after the child’s tongue looked red and there was an unusual dark redness around the tooth being treated.
After the 3pm call by the dentist, the alarm was sounded amongst colleagues and a litre bottle of liquid pipe cleaner was identified in the Central Sterile Services Room (CSSR) as the probable source of the contamination.
National Poisons Centre
Personnel at the clinic contacted the National Poisons Centre for advice to deal with the incident.
In their report, the investigators established that Red Streak was added to the water supply some time between 3 and 4 October, adversely affecting the children on 4 and 5 October.
However, HSE investigators were unable to identify the source of the bottle of Red Streak and could not establish when and by whom the pipe cleaner was added to the water supplying the dental equipment.
The investigators did however find that internal security within the dental clinic was poor – domestic cleaning products were not stored securely; there was a lack of written standard procedures and staffing in the CSSR was not adequate to ensure safe work practices.
Kate Duggan, Head of Primary Care with HSE Mid West Community Healthcare, yesterday said: “Our investigation as to exactly 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, as we have acted on those findings.”
The report’s recommendations include the installation of a swipe access security system for all doors in the dental clinic and that a senior administrative dental surgeon should be appointed as a matter of urgency.
Senior HSE management have arranged to meet with both the dental department staff and the parents of the children to provide them with an overview of the findings of the investigation and a copy of the report of the investigation team.
A spokesman for the HSE stated: “All of the findings are being responded to and new processes being put in place and monitored.”
Today one of the parents concerned, Jill Morris, said that what occurred “shouldn’t have happened”.
Morris said that her 12-year-old daughter suffered from “little white ulcers in her mouth” as a result of coming into contact with the Red Streak-contaminated water.
Morris added: “My daughter came off quite lightly.”
Ann Norton, local independent councillor and member of the HSE West Regional Health Forum, said that questions remain as a result of the report.
“These children were poisoned and to come out with an inconclusive report is not good enough for the parents involved and I don’t think it is good enough for parents of children who use the clinic,” she said.
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