A hospital has agreed to pay damages to the family of a confused patient who died after drinking a bottle of hand sanitiser gel which contained as much alcohol as a litre of gin.
John Haughey, 76, would have been almost six times over the drink-drive limit after consuming the contents of the bottle which had been attached to the bottom of his bed at Hull Royal Infirmary.
He drifted in and out of consciousness and died six days later of bronchopneumonia.
Following his inquest earlier this year, Hull coroner Professor Paul Marks wrote to the chief executive of NHS England to warn that similar deaths could occur if changes were not introduced.
In his letter he said there was a "tension" between providing gels to prevent infection and the safety of vulnerable or confused patients who might consume them.
Mr Haughey was admitted to hospital in September 2015 because his family was concerned about him becoming unwell, forgetful and increasingly confused.
On the fifth day he drank the gel which contained ethyl alcohol at a concentration of around 75%.
His blood alcohol level was measured at 463mg per 100ml of blood - the legal limit for driving is 80mg - and 10 hours later it was still 354mg.
Hull and East Yorkshire Hospitals NHS Trust has admitted breach of its duty of care as part of a legal action by the patient's family, and agreed to pay an undisclosed, five-figure sum in damages.
The patient's daughter, Diane Atkin, said: "It has been a disgrace from start to finish.
"We were kept in the dark with very little information by the Trust over what had happened to my father, how it had ever been allowed to happen and the failings in treatment after he had swallowed the gel."
Ms Atkin added that the gel bottles were easily unscrewed and were "an accident waiting to happen".
She also felt that her father had received "poor care" afterwards, claiming he was not monitored properly.
The coroner said staff expected Mr Haughey to metabolise the alcohol, and that his airway was unprotected for seven hours.
Ms Atkin said her father had lived independently before being admitted to hospital, and although he was confused he had not been diagnosed with dementia.
Michelle Tebbutt, of the medical specialists Hudgell Solicitors, said the amount Mr Haughey had drunk meant it was certain to lead to unconsciousness and the need for breathing support.
Despite this, no immediate action was taken by medical teams to assist his breathing.
Ms Tebbutt said it was a tragic case, adding: "He (Mr Haughey) was unresponsive for close to seven hours before becoming completely unconscious, by which time his airway was in jeopardy.
"There was a risk of aspiration at all times. It was inevitable that he would become unconscious, and not to take immediate action was a serious failing in care."
Mike Wright, executive chief nurse for Hull and East Yorkshire Hospitals NHS Trust, said: "We would like to offer our apologies and our sincere condolences to Mr Haughey's family for their loss and for the distress they have experienced.
"Whilst acknowledging that the standard of care provided did not meet that which the Trust strives to achieve, we hope Mr Haughey's family take comfort from knowing that subsequent actions taken by the Trust have been robust, and that HM Senior Coroner for Hull, Professor Paul Marks, is satisfied that those actions will prevent similar incidents occurring in the future."
Staff now carry their own sanitisers and the trust has brought in lockable dispensers.
NHS England said in a statement: "The NHS takes issues such as these extremely seriously and partner organisations are working together to explore how safety around these products can be improved."