Hospital Washed Patient’s Lungs With Detergent Instead Of Saline By Mistake

A British hospital mistakenly washed an elderly patient’s lungs with a cleaning solution instead of saline, according to a recently released internal investigation report by National Health Service.

William Hannah, 68, from Bolton, England, was admitted to the Salford Royal Hospital after he met with an accident in September 2017. Hannah was diagnosed with serious injuries, including a traumatic brain injury and multiple fractures, Manchester Evening News reported.

Despite receiving treatment, he was shifted to the Critical Care Unit and placed on a ventilator after his condition continued to deteriorate. That is when he developed a lung infection, causing the doctors to opt for a bronchoscopy, a procedure to clear the patient’s lungs in order to help him breathe better.

The investigation found that the hospital failed to stock up equipment needed to perform the emergency procedure and hence, a staff member was told to fetch some saline so that a small amount of the fluid could be introduced into the lung and it could be washed out.

However, due to mislabeling of the bottles or miscommunication, the staff handed a detergent solution – used for cleaning hospital equipment – to the doctor, who washed the patient’s lungs with it. When the physician realized the mistake, another “thorough washout of the right lung” was carried out.

After 33 hours, Hannah died. It is still unclear if the patient’s death was a direct result of the error on the hospital’s part. The report, however, couldn't determine the grandfather-of-three’s cause of death and concluded that the mistake was made due to a number of factors.

“Following investigation it was determined that the inadvertent instillation of the incorrect fluid into the patient’s lungs was caused by a number of human factors. These factors include – un-stocked trolley; distraction by other life critical tasks; lack of clear two-way communication; no labelling of bottle; inadequate staff training; and lack of COSHH [Control of Substances Hazardous to Health Regulations] risk assessment,” the report said.

It added: “The clinical impact of the errors on the patient is unknown at this point therefore we have requested an independent toxicology report to support the pathology results and coronial inquest."

Since the incident, new measures have been introduced in the hospital to ensure that such mistakes are not repeated in the future.

“We once again offer our deepest sympathies to William Hannah’s family for the loss of their much-loved family member. We have carried out a comprehensive investigation examining thoroughly the care Mr. Hannah received. We have since shared this information with his family,” Dr. Pete Turkington, medical director at Salford Royal NHS Foundation Trust, said.

He added: “The review of Mr. Hannah’s care at Salford Royal highlighted that he did not receive the high standard of care we always pride ourselves on delivering and we apologize unreservedly to his family for this. We have since introduced new measures to ensure something like this will not happen again. We continue to work with the coroner to determine whether any failings by the trust caused or contributed to Mr. Hannah’s death. The coroner will hear the inquest into his death next year."

Manchester law firm JMW was hired to investigate the matter further.

"This incident has been very traumatic for William’s family who have not only had to deal with his death but also these appalling circumstances. Their grief has been compounded by this terrible error and they understandably would like to know how something so shocking and avoidable could occur,” Eddie Jones, head of clinical negligence at law firm JMW, said.

Meanwhile, after learning about the hospital’s mistake, Hannah’s relatives said they were “shocked and angry.” Lisa, 44, Hannah’s daughter said: "This was an appalling and unbelievable mistake."