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Care home resident died after swallowing bleach tablets.

A CARE home resident who died after eating bleach tablets that looked like mints waited more than three hours for an ambulance to take him to hospital, an inquest has heard.

Diabetic dementia patient Joe Serginson, 85, grabbed a tub from a cleaners' trolley and swallowed the dissoluble disinfectant as staff dealt with a mess.

Staff called five times for an ambulance and a series of crews were asked to attend Balmoral Court home, Newcastle, but were diverted to other cases.

It was after the fifth call to the North East Ambulance Service (NEAS), that a crew attended and Mr Serginson was taken to the city's Royal Victoria Infirmary, just under an hour later.

Medics decided Mr Serginson was unlikely to recover from the effects of the corrosive chemical and he was kept comfortable until he died four days later.

The inquest heard that pathologist, Peter Cooper, concluded Mr Serginson died from respiratory failure after eating chlorine tablets.

Newcastle assistant coroner, Karin Welsh, was told how the ambulance service had reached the stage of "clinical escalation" earlier that day, meaning there were too many jobs for the crews available.

NEAS complaints investigator, Ruth Jackson, told the inquest that "clinical escalation" happened regularly and was to be addressed by more recruitment.

The cleaner, Jamie Forbes, said the tub of chlorine tablets, which were round and white and looked like extra strong mints, was on the top shelf of her trolley.

There were about 16 male residents on the home’s top floor and staff knew to keep an eye on Mr Serginson, who would go into other people's rooms to pinch chocolates, despite suffering from diabetes.

The home’s senior carer, Jennifer Bolam, said she was cleaning a dado rail when she spotted Mr Serginson with the tub.

She said: "It was so fast. He had put his hand in the jar, grabbed the tablets and put them in his mouth. I screamed 'Joe' and grabbed hold of him. He was chewing so fast and I put my hand into his mouth to get the tablets out." Other staff members raced to the scene to help after she screamed.

Mrs Bolam said they were advised to give Mr Serginson nil by mouth when they made the 999 call. She said colleagues discussed the case afterwards and expressed surprise he could have removed the lid of the tub.

She said Mr Serginson would often say he was hungry and would pick up items and try to eat them.

An acute medicine specialist, Dr Christopher Gibbons, said the ambulances made no difference to Mr Serginson's chances of survival. He would have aspirated matter into his lungs soon after eating the tablets and, after that, there was little to be done for a frail patient.

The coroner said she looked at two issues - the delayed ambulance and the fact Mr Serginson could get hold of the tablets.

She said the 999 call handler initially graded the incident as requiring an ambulance within 30 minutes, but there was an understanding at the home that the crew could be delayed by more urgent patients.

Ms Welsh said in a second call, a nurse at the home appeared to say an ambulance was needed more urgently before agreeing she could care for Mr Serginson while they waited.

The coroner also ruled the chlorine tablets should not have been on the trolley and the assumption dementia patients could not open a childproof lid was naive.

Regional manager for the home’s owners, Crown Care, Louise Spoors, said the group no longer used the tablets and had introduced trolleys with lockable cupboards.

In a narrative conclusion, the coroner ruled: "Joe died as a result of ingestion of chlorine tablets not stored securely."



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