The HSE has been criticised after an inquiry into how drain cleaning fluid was used rather than an approved dental product in the treatment of more than 40 children in Co Clare returned an inconclusive verdict.
Last October the HSE issued a health advisory notice, an apology and started an investigation into the incident at its dental clinic in Ennis.
The inquiry found that the ‘Red Streak’ drain cleaner product used to clean the mouths of children included potassium hydroxide, at a concentration of 5 per cent.
The report states that a parent alerted clinic staff to an adverse reaction suffered by her daughter but the source was not identified for another 4½ hours.
Fifteen of the 43 children identified as being affected by the incident reported adverse symptoms with some complaining of mild irritation or burning sensations in their mouths.
The HSE acknowledged that the treatment experience of the children “may have a psychological effect on them and their families, and in their confidence in the dental service going forward”.
A parent of an affected child, Jill Morris, said her daughter (12) developed “little white ulcers in her mouth” as a result of the contaminated water. She said the incident “shouldn’t have happened”.
Kate Duggan, of the HSE Mid West, said the investigation had proven "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".
The findings included that “internal security” in the clinic was poor; that “domestic cleaning products are not stored securely”; staffing in the sterile room “is not adequate to ensure safe work practices”; and that “written standard operating procedures” were lacking.
The HSE issued a further apology to the families of those affected by the incident and a spokesman said “all of the findings are being responded to and new processes being put in place and monitored”.
Cllr Ann Norton, a member of the HSE's Health Forum (West), said an inconclusive finding in the case was "not acceptable" .
She said the claim that the inquiry would ‘reduce if not eradicate’ the chance of the same thing happening again was “completely ridiculous as an incident like this should never have had happened in the first place”.
Cllr Norton added that “patient care should be paramount and unfortunately as we see over recent years that patient care is too far down the list of their priorities”.