The multi-decade household humidifier disinfectant poisoning tragedy (HHDT) in South Korea highlights the importance of investigating government failures. This study aims to identify and discuss key failures and shortcomings in the South Korean authorities’ approach to regulating humidifier disinfectants (HDs) and monitoring cases of chemical poisoning. We reviewed both the HD risk prevention measures that the South Korean Ministry of Environment (KME) should have implemented under the Toxic Chemicals Control Act (TCCA) (1991–2013).Polyhexamethylene guanidine phosphate (PHMG), a new chemical, was approved for use as a disinfectant under the TCCA. KME declared PHMG non-hazardous based solely on preproduction documentation provided by the industry. In addition, the Korea Disease Control and Prevention Agency (KDCPA) failed to detect the HHDT that had accumulated each year for more than a decade. KME’s neglect of its responsibilities, coupled with KDCPA’s lack of chemical poisoning surveillance systems, led to the accumulation of widespread HHDT.

The multi-decade household humidifier disinfectant poisoning tragedy (HHDT) in South Korea highlights the importance of investigating government failures. This study aims to identify and discuss key failures and shortcomings in the South Korean authorities’ approach to regulating humidifier disinfectants (HDs) and monitoring cases of chemical poisoning. We reviewed both the HD risk prevention measures that the South Korean Ministry of Environment (KME) should have implemented under the Toxic Chemicals Control Act (TCCA) (1991–2013).Polyhexamethylene guanidine phosphate (PHMG), a new chemical, was approved for use as a disinfectant under the TCCA. KME declared PHMG non-hazardous based solely on preproduction documentation provided by the industry. In addition, the Korea Disease Control and Prevention Agency (KDCPA) failed to detect the HHDT that had accumulated each year for more than a decade. KME’s neglect of its responsibilities, coupled with KDCPA’s lack of chemical poisoning surveillance systems, led to the accumulation of widespread HHDT.

The multi-decade household humidifier disinfectant poisoning tragedy (HHDT) in South Korea highlights the importance of investigating government failures. This study aims to identify and discuss key failures and shortcomings in the South Korean authorities’ approach to regulating humidifier disinfectants (HDs) and monitoring cases of chemical poisoning. We reviewed both the HD risk prevention measures that the South Korean Ministry of Environment (KME) should have implemented under the Toxic Chemicals Control Act (TCCA) (1991–2013).Polyhexamethylene guanidine phosphate (PHMG), a new chemical, was approved for use as a disinfectant under the TCCA. KME declared PHMG non-hazardous based solely on preproduction documentation provided by the industry. In addition, the Korea Disease Control and Prevention Agency (KDCPA) failed to detect the HHDT that had accumulated each year for more than a decade. KME’s neglect of its responsibilities, coupled with KDCPA’s lack of chemical poisoning surveillance systems, led to the accumulation of widespread HHDT.

The multi-decade household humidifier disinfectant poisoning tragedy (HHDT) in South Korea highlights the importance of investigating government failures. This study aims to identify and discuss key failures and shortcomings in the South Korean authorities’ approach to regulating humidifier disinfectants (HDs) and monitoring cases of chemical poisoning. We reviewed both the HD risk prevention measures that the South Korean Ministry of Environment (KME) should have implemented under the Toxic Chemicals Control Act (TCCA) (1991–2013).Polyhexamethylene guanidine phosphate (PHMG), a new chemical, was approved for use as a disinfectant under the TCCA. KME declared PHMG non-hazardous based solely on preproduction documentation provided by the industry. In addition, the Korea Disease Control and Prevention Agency (KDCPA) failed to detect the HHDT that had accumulated each year for more than a decade. KME’s neglect of its responsibilities, coupled with KDCPA’s lack of chemical poisoning surveillance systems, led to the accumulation of widespread HHDT.