Inquest jury criticises Brighton hospital bosses over death of patient who drank cleaning fluid

An inquest jury has criticised bosses at a Brighton hospital over the death of a patient who drank cleaning fluid.

Joan Blaber, 85, drank Flash cleaning fluid left in a jug by her bedside at the Royal Sussex County Hospital in September last year.

She died six days later from respiratory failure. She was suffering from chronic distress with her breathing and pneumonia brought on by chemical pneumonitis – an inflammation of her lungs – as a result of having ingested the cleaning fluid.

The jury reached a unanimous verdict, delivered as a narrative, which coroner Veronica Hamilton-Deeley said should be reported in full.

It criticised the management of the Royal Sussex, by Brighton and Sussex University Hospitals NHS Trust, with the coroner adding that she would be writing to the trust to try to ensure that lessons are learnt to prevent future deaths.

The verdict of the three men and six women of the jury said: “Joan Catherine Blaber died six days after ingesting cleaning fluid on (Sunday) 17 September 2018 in the following circumstances.

“Mrs Blaber was admitted to the Royal Sussex County Hospital on 22 August 2017 with symptoms of minor strokes.

“By 7 September 2017 she was making progress and doctors were considering discharge options. But general frailty and health issues meant she was unable to be discharged.

“On (Sunday) 17 September 2017 Mrs Blaber`s clear water jug was replaced with a solid green water jug containing a cleaning fluid. This was later used to dilute cordial which she drank while taking her medication.

“Evidence leads us to believe there was widespread confusion surrounding the water jug system that was in place and that jugs were being misused.

“Understanding and implementation of cleaning procedures were inconsistent and inadequate among agency and trust cleaning staff.

“Furthermore we find that the management failed to direct and monitor staff, adhere to and enforce the Control of Substances Hazardous to Heath Regulations (COSHH), leading to ongoing breaches of regulation.

“In-house training for facilities and estates (staff) was not optimised due to the failure to monitor post-training practices adequately. Training was also not guaranteed to the same standard for agency staff.

“Management missed an opportunity to learn and disseminate lessons from a 2016 incident on the same floor of the hospital involving the drinking of cleaning fluid which had been entered into the Datix incident database.

“Based on the evidence, we find this contributed to inappropriate practices in the hospital which were not addressed due to a culture of non-reporting.

“Serious communication failures in the hospital opened the way to misunderstanding of procedures, errors in practice and resulted in a failure to implement lessons that could have been learned.

“We found this contributed to Mrs Blaber’s safety being compromised.”

After the jury delivered its verdict, solicitor Jonathan Austen-Jones, from Healy’s, read a statement on behalf of the family. It said: “As a family we continue to struggle to come to terms with what happened to Joan.

“The inquest was both daunting and traumatic at times, listening to the evidence.

“We wish to thank both the coroner and police for conducting a widespread investigation.

“It is our sincere hope that the hospital trust learns lessons and takes the appropriate remedial action to prevent another death in these circumstances particularly when it should never have happened in the first place.

“We would like to make it clear we do not blame nurse Alba Duran personally for Joan’s tragic death.

“Finally we would like to thank our friends and family for their kindness and support over the last year.”

The coroner said: “The jury have recorded serious failings. They have identified and explored them and found them to be directly related to Joan’s death.

“In the light of this I shall be making a ‘regulation 28 report’. This is a report requiring action to prevent other further possible deaths.

“In my opinion, this inquest has shown that action should be taken to prevent the occurrence or continuation of the failings that the jury has identified and thus eliminate or reduce the risk of deaths created by these failings.”

The report would be sent to hospital trust chief executive Marianne Griffiths and other key staff at the Royal Sussex.

A copy will also go to the Care Quality Commission. The CQC is carrying out an inspection of the hospital next week.

Mrs Griffiths has 56 days to reply to the coroner’s report, stating what steps are being taken to prevent future deaths from the concerns identified.

The coroner also said: “Many people, particularly local people, will be anxious about the events surrounding Joan’s death and will be worried about their own safety.

“I hope that they will receive some reassurance from the rigorous inquiries which have been undertaken by the police, the CQC and in particular by the jury.

“We should be less safe and more worried if such matters were examined so they could be put right.”

Brighton and Sussex University Hospitals chief nursing and patient safety officer Nicola Ranger said after the inquest had ended: “I would like to start by reiterating how sorry I am for the death of Joan Blaber.

“On behalf of Brighton and Sussex University Hospitals, I apologise to Mrs Blaber’s family and all those who loved and miss her.

“Since Mrs Blaber’s death, the trust has worked hard to put processes in place to prevent a similar incident happening in future.

“We have worked with our regulators, the police and partners, including Healthwatch, to ensure our response has been robust.

“This has included providing staff training, assessing our use of all our cleaning products and standardising the way we store and use potentially hazardous chemicals.

“Our staff work incredibly hard and demonstrate outstanding care and compassion for our patients every day.

“We are sorry, we have learned and we will continue to make every effort to improve.”