15 children suffered mouth ulcers after dental incident

Fifteen Clare children suffered from blistering and mouth ulcers following the contamination of water containers with diluted drain cleaner at the Ennis Dental Clinic, a new report has revealed.

In total, 43 children and four Dental Treatment Services Scheme (DTSS) medical card patients were exposed to the water supply on October 4 and 5, according to an inconclusive HSE investigation.

This contamination resulted in fifteen children suffering adverse localised symptoms ranging from mild burning sensation to blistering and ulceration of the mouth.

The report acknowledges that the treatment experience for the children was “devastating” and that it may have a psychological effect on them and their families, and in their confidence in the dental service going forward.

On the afternoon of October 5, it was established that the water supplying the dental equipment in the Ennis Dental Clinic was contaminated.

A bottle of red streak, a liquid pipe opener/cleaner containing Potassium Hydroxide 5% was found in a cupboard in the Central Sterile Services Department (CSSD) room and considered to be the possible contaminant.

The investigation team were unable to identify the source of the bottle of red streak and could not establish when and by whom the Red Streak was added to the water supplying the dental equipment in the clinic.

Kate Duggan Head of Primary Care with HSE Mid West Community Healthcare said their investigation as to exactly how this happened is inconclusive but it is obvious to us that four incidental findings will now greatly reduce if not eradicate the possibility of this happening again, as we have acted on those findings.

These findings stated internal security within the dental clinic is poor, domestic cleaning products are not stored securely in the clinic, staffing in the CSSD room is not adequate to ensure safe work practices and there is a lack of written standard operating procedures (SOPs).

Senior management have arranged to meet with both the Dental Department Staff and the parents of the children to provide them with an overview of the findings of the investigation and a copy of the report of the investigation team.  

All of the findings are being responded to and new processes being put in place and monitored.

The HSE has also sincerely apologised to the children and families affected by this incident.

Dan Danaher