T2022-02 Death of a resident caused by a hazardous substance in a nursing home in South Savo in November 2022

In the early hours of Saturday 26 November 2022, an accident occurred at a nursing home in Mäntyharju, South Savo, where an elderly resident was exposed to harmful consumer chemicals. Despite rapid access to treatment, the resident died two days later in hospital from serious complications caused by poisoning.

The nursing home had two pantries, where residents’ and staff’s dishes were washed after meals. The drains in the sinks were frequently blocked. It had become customary for the staff to use drain cleaner granules to open the blocked drains instead of calling a maintenance company to unblock them. It is important for nursing homes to have well-functioning daily routines. However, the nursing home staff should not use drain cleaner granules due to the safety risk involved.

The nursing home’s pantry was part of an open living area, which meant that residents also had full access to the drawers and cupboards. The drawers were not kept locked, even though all the consumer chemicals stored in them posed an obvious safety risk. The nursing home had not specifically decided or agreed on a policy on the use of locks over the years.

The container of drain cleaner granules had a child-resistant cap and its label warned of the danger of the substance. However, the nursing home had not taken into account the hazardous nature of consumer chemicals and their risk to client and patient safety, especially for people with memory disorders. In nursing homes, a number of risks related to mobility have generally been addressed in different ways, but the guidelines do not specifically address risks related to safety in the living environment, such as consumer chemicals. The use and storage of hazardous chemicals is not systematically addressed in the self-monitoring plan, emergency plan or induction training.

The Safety Investigation Authority recommends that:

• The National Supervisory Authority for Welfare and Health, in cooperation with Regional State Administrative Agencies, shall develop guidelines for self-monitoring plans for social and health care service providers to take more explicit account of risks in the living environment, such as the use of locks for the storage of consumer chemicals.

In addition to this, the Safety Investigation Authority repeats and extends the recommendation issued in the previous investigation that:

• The Ministry of Social Affairs and Health shall ensure that a data collection and sharing system is developed in the social and health care sector. This will be used to collect relevant information on all incidents that have seriously compromised client and patient safety and to form and publish conclusions relevant to improving safety for the benefit of the whole sector.