NHS employers have been told to review their use of sachets of polymer gel granules after it emerged that they can cause death or severe harm if swallowed.
Regulator NHS Improvement, which sent out a safety alert yesterday to organisations, said it had been told of a patient dying of asphyxiation after ingesting a sachet left in an empty urine bottle in their room.
“While safety advice following previous fatalities focused on the need for individual risk assessment, recent incidents suggest this is insufficient”
The “superabsorbent” granules are widely used in health and social care, typically as sachets placed in urine and vomit bowls to absorb liquid and prevent infections.
They are not toxic but if put in the mouth will expand on contact with saliva, risking airway obstruction.
NHS Improvement has advised healthcare providers to consider using other products, which are less likely to be swallowed.
A review of the NHS’s national reporting and learning system found details of 15 non-fatal incidents in acute, community and mental healthcare settings in the past six years related to the granules.
In some of incidents, patients may have mistaken the sachets for sweets, or sugar or packets of salt. Other incidents may have been attempts at deliberate self-harm, noted NHS Improvement.
Some patients opened the sachets, tipped the contents onto food and drinks and swallowed them, or put whole sachets into their mouth, said the regulator.
”Sachets intended for use by one patient have been picked up by others and many inpatient units have patients who are confused or at risk of self-harm”
In one incident, a patient was found with what appeared to be sugar in their mouth. When staff realised it was an expanding agent used in urinal bottles, the patient spat out some of the product but they were unable to swallow.
The patient was sent to A&E by ambulance because of the risk of “expansion and asphyxiation”. Staff did not know how the patient got the sachet, NHS Improvement said.
“While safety advice following previous fatalities focused on the need for individual risk assessment, recent incidents suggest this is insufficient to protect patients, as sachets intended for use by one patient have been picked up by others and many inpatient units have patients who are confused or at risk of self-harm,” NHS Improvement said.
Healthcare providers are encouraged to “review their overall approach to using these products, including consideration of whether alternative products less likely to be ingested can be adopted,” said the regulator.
It also suggested employers should consider whether gel granules should be reserved for “exceptional rather than routine use, and securely stored until those circumstances arise”.