Murphy, Maxwell

89y · Male·multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quaternary ammonium compound)

An 89-year-old man with severe dementia died from multi-organ failure following ingestion of concentrated Bacban (quaternary ammonium compound) left in his bathroom at an aged care facility. The cleaning staff member inadvertently left the chemical bottle in the resident's room. When discovered coughing, salivating and reporting burning, nursing staff called the Poisons Information Centre but provided incomplete information—stating the patient had consumed 10-15ml and was asymptomatic, when he was actually displaying significant symptoms and the actual quantity was unknown. The PIC advised observation only. Nursing staff failed to escalate to hospital despite the patient later coughing blood. Hospital admission was delayed approximately 2.5 hours. Clinical lessons: (1) always assume worst-case ingestion volume when unwitnessed; (2) provide complete clinical information to PIC including symptoms and medications; (3) escalate immediately when corrosive ingestion is suspected with any symptoms; (4) implement systems to prevent chemicals remaining in resident spaces; (5) ensure adequate monitoring and documentation of vital signs.