The Dangers of Unsafe Chemical Storage in Healthcare | Case Study

This case highlights the serious risks associated with chemical storage and the handling of non-oral substances in clinical settings, particularly where patients are cognitively impaired and unable to recognise danger.

The patient, who had a diagnosis of dementia, was nearing discharge following a period of stabilisation. During what should have been a routine phase of care, she was exposed to Potassium Permanganate (PP), a chemical prescribed for use as a leg soak. The substance was later believed to have been ingested after being left unattended in a medicine pot on the patient’s bedside locker during a drug round.

What followed was a rapid and severe deterioration. The patient developed airway swelling, began choking, and was subsequently placed on an end-of-life care pathway. She later died.

An Apex medication error expert witness was instructed to review the care provided. Their findings identified a series of fundamental failures in how the substance was prescribed, labelled, stored, and handled. Despite well-established safety risks associated with Potassium Permanganate - particularly given its tablet form - it had been stored alongside oral medication and managed in a way that exposed the patient to clear and avoidable harm.

A breakdown in basic safety processes

The sequence of events revealed multiple gaps in routine clinical practice.

A bank nurse had been redeployed mid-shift and received only a limited handover before commencing a medication round. During this process, a PP tablet was removed from the medication locker, placed into a medicine pot, and left unattended on the patient’s table.

The patient, who was known to display impulsive behaviour and frequently handled nearby objects, was observed placing the tablet into her mouth. Within moments, she began coughing and choking.

Subsequent ENT assessment identified black staining and swelling within the upper airway, consistent with chemical exposure.

Known risks, foreseeable harm

This incident raised serious concerns not only about individual actions, but also about wider system failures.

Potassium Permanganate is a corrosive substance with well-documented risks if ingested. Its tablet form creates an inherent risk of confusion with oral medication, particularly where storage, labelling, and handling practices are not robust.

In this case, a hazardous chemical had been stored in an oral medication environment and left within reach of a vulnerable patient, without supervision, during a drug round. The risk was both obvious and foreseeable.

What should have happened

From a nursing and medication safety perspective, the expectations are clear.

Substances such as Potassium Permanganate should be:

• Stored separately from oral medications

• Clearly labelled as “for external use only”

• Handled in a way that avoids any overlap with routine medication rounds

• Kept out of reach of patients, particularly those with cognitive impairment

  
  

In addition, staff should be familiar with COSHH guidance and trained in the safe handling of hazardous substances. Unused items should never be left accessible at the bedside.

In this case, none of these safeguards were reliably in place.

A system failure, not a single error

While there was some uncertainty regarding the exact mechanism of ingestion, the overall picture was clear. The environment and processes in place failed to protect the patient from avoidable harm.

Postmortem findings later confirmed pharyngeal erosion consistent with a chemical burn, and the patient’s airway compromise developed in the hours following the incident.

The expert did not comment on causation. However, they concluded that the management of Potassium Permanganate fell below the expected standard across multiple areas, including prescribing, labelling, storage, supervision, and administration.

Why this case matters in chemical storage

This case serves as a stark reminder that the safe handling of non-oral substances is a core patient safety issue, not a peripheral one.

Where patients are cognitively impaired, the margin for error is significantly reduced. Basic safeguards - such as safe storage, clear labelling, and appropriate supervision - are not optional. They are essential.

When those safeguards fail, the consequences can be immediate, severe, and irreversible.