Case 1: Intentional consumption

In 2013 a 30-year-old woman was admitted to a mental health facility in an English tertiary care hospital. Twenty days later she was detained under the provisions of the Mental Health Act 1983 and given venlafaxine, an antidepressant medicine. She passed away 3 days later, found in her hospital bed with a container of Purell hand sanitising gel (containing ethanol and isopropanol at 66% weight per volume) beside her. The gel was readily accessible to patients on the ward from a communal dispenser, and patients were allowed to fill cups or other containers to keep in their rooms. A post-mortem blood analysis found “214 mg of alcohol in 100 mL of blood”. The medical cause of death was “ingestion of alcohol and venlafaxine”, and the coroner concluded that the combination of these substances caused the patient’s breathing to be suppressed, resulting in death.

The coroner’s report identified four concerns (see box 2) which were addressed to the UK’s Department of Health and the NHS Trust.2 Under regulation 28 of the Coroners’ (Investigations) Regulations 2013, parties who receive the report have 56 days to respond to the coroner, outlining actions taken or proposed, with a timetable for action; otherwise, the addressees must explain why no action is proposed. The Department of Health responded 59 days later describing national guidelines and strategies to prevent suicides.11 They also alluded to data from the National Reporting and Learning System, which can only be accessed if you are a general practitioner or pharmacist or have an NHS email. Thus, no actions were undertaken or proposed by the Department of Health.

At the time of writing (August 2020) and published (November 2020) this article, a response from the NHS Trust was not available on the Judiciary website, making it 6 years overdue.2 A Freedom of Information (FOI) request to the Trust revealed that a response may have been received by the Coroner’s Office which reported replacing wall-mounted sanitisers with alcohol-free alternatives, and that the Trust had taken steps to review access to and use of sanitisers, as well as raising awareness of the potential risks associated with the ingestion of alcohol-based hand sanitisers with staff.11 However, there are no mechanisms for verifying or monitoring the implementation of these actions, nor is it possible to determine whether the actions became standard practice and are still being endorsed across the Trust.

Case 2: Unintentional consumption

In 2015 a 76-year-old man developed acute ethanol toxicity after ingesting an unknown quantity of Purell Advanced Hygienic Hand Sanitising Foam, containing about 75% ethanol, which was attached to the foot of his bed while he was an inpatient in an NHS hospital in England. He had a history of agitation and depression, which was being treated with antidepressants, and had a 9-month history of increasing confusion, with some evidence that he might be developing vascular dementia. His blood ethanol concentration was 463 mg/dL (100 mmol/L) initially and 354 mg/dL (77 mmol/L) 10 hours later. He was given lorazepam and haloperidol and treated with ventilation in the intensive care unit (ICU), with a plan to allow the alcohol to be naturally metabolised. After removal of his endotracheal tube in the ICU, he developed aspiration pneumonitis and bilateral bronchopneumonia. He died 6 days later and the causes of death were recorded as: (1a) bronchopneumonia; (1b) acute alcohol toxicity; (2) acute delirium and coronary artery atherosclerosis.

The coroner’s primary concern (see box 3), addressed to NHS England, was that lessons from this incident were not widely communicated within the NHS or to the public. No response was available from NHS England at the time of writing (August 2020) and published (November 2020) this article, making it more than 3 years overdue under regulation 28 of the Coroners’ (Investigations) Regulations 2013.3 After the inquest, a news article reported that the Trust had introduced lockable dispensers and staff were carrying their own sanitisers.12 However, there are no mechanisms for verifying or monitoring these actions, nor is it possible to determine whether the imposed actions are still standard practice. In another news article the medical director of NHS England stated that they could not directly influence the public’s use of alcohol-based sanitisers, but that he would flag the risk with the Medicines and Healthcare products Regulatory Agency (MHRA), and that NHS Improvement would update the coroner on both steps as developments emerge.13 But no record of whether this communication occurred is available on the Judiciary website.3

Encouraging hand hygiene while mitigating harms

Hand hygiene is the cornerstone of infection control, and efforts are still needed to improve practices, particularly during the COVID-19 outbreak. In healthcare facilities the WHO’s “My 5 Moments for Hand Hygiene” should be performed, and increasing the availability of alcohol-based hand sanitisers in point-of-use areas can improve adherence.14 In most clinical settings, alcohol-based hand sanitisers are the preferred approach, unless hands have visible contamination with blood, body fluids, proteinaceous material or are exposed to spore-forming organisms, when hands should be washed with soap, water and drying agents.15 In all other settings, washing hands with soap and water is a simple and effective way to decrease the spread of pathogens and infections. If soap and water are not available, alcohol-based hand sanitisers can be used. Thus, the deaths discussed in this article should not deter the use of hand sanitisers. However, these deaths have serious safety implications for healthcare facilities, the public and other private settings. The deaths provide an opportunity to develop and implement mitigation strategies (see box 4), and are an opportunity to educate healthcare professionals and the public in harm reduction.

Had appropriate actions been taken at a national level by the UK’s Department of Health in 2014, the death described in Case 2 and the hundreds of poisonings reported to the NPIS in 2019 and 2020 (figure 1) might have been prevented. The combination of increased demand and exposure to alcohol-based hand sanitisers, and the negative impacts of the COVID-19 outbreak on mental health, social supports, financial security and health services is a cause of serious concern.16 17 This complex interplay of issues may lead to a further increase in poisonings and deaths that could be mitigated if recommendations from these deaths were implemented.

While governments and public health authorities have successfully heightened our awareness of and need for better hand hygiene during the COVID-19 outbreak, they must also make the public aware of the potential harms and encourage the reporting of such harms to poisons information centres. Data reported to poisons centres should be monitored, openly shared, and used to design and implement mitigation strategies to serve patient and public safety.