David Hayes

I am Michael James Pemberton, HM Area Coroner for the coroner area of Manchester (West).

On 29 April 2025 I commenced an investigation into the death of David Joseph HAYES aged 82. The investigation concluded at the end of the inquest on 17 July 2025. The conclusion of the inquest was Accident, and the medical cause of death was 1a Pneumonitis 1b Aspiration due to ingestion of a chemical substance.

The deceased suffered from Dementia in Alzheimer’s disease and was admitted to the Royal  Bolton Hospital on 16 April 2025 following a previous attendance and discharge due to  accidental ingestion of a washing detergent on 15 April 2025. This had occurred when he had made a cup of tea at home and put washing detergent into the cup instead of milk after an  apparent confusion. He had vomited following the ingestion and it is likely that he aspirated. On admission, he was discovered to be suffering from suspected pneumonitis which was considered likely to have arisen from aspiration of detergent and stomach acid when vomiting after the accidental ingestion. He received treatment by antibiotics, steroids and analgesia. He experienced atrial  fibrillation, and his heart rate remained inadequately controlled despite treatment. He  continued to decline, and palliative care was provided. He passed away on 21 April 2025.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:

1. During the course of evidence it was noted that the plastic bottle like packaging in  which the white liquid washing detergent was contained was confused by the  deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent  container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:

a.   The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused – here milk b.   The shape of the packaging could be misconstrued in these circumstances c.    The screw top lid with no child or resistance protection is easily accessible.

1. The level of printed warnings on the labelling was not explored during the hearing,  but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
2. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and  make them less accessible.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.