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‘Serious failings’ led to hospital death of patient who drank cleaning fluid, inquest rules



“Serious failings” at a hospital led to the death of an elderly patient who drank Flash cleaning fluid after it was put in a water jug on her bedside table, an inquest has ruled.

Joan Blaber died six days after drinking the floor cleaner at the Royal Sussex County Hospital in Brighton where she was being treated.

The 85-year-old, of Lewes, East Sussex, had been admitted with a minor stroke on 22 August last year.

Her condition deteriorated after she drank the detergent on 17 September after it was left in a water jug on her bedside table.

Jurors at the eight-day inquest at Brighton and Hove Coroner’s Court returned a narrative conclusion on Thursday.

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

“Understanding and implementation of cleaning procedures were inconsistent and inadequate amongst agency and Trust cleaning staff.”

They added “management failed to direct and monitor staff” and did not enforce regulations related to hazardous substances “leading to ongoing breaches”.

Senior coroner Veronica Hamilton-Deeley said she would be writing to the Brighton and Sussex University Hospitals NHS Trust in the form of a report “requiring action to prevent other further possible deaths”.

She said: “The jury have recorded serious failings, they have identified and explored them and found them directly related to Joan’s death.

Joan Blaber was being treated at the Royal Sussex County Hospital
Joan Blaber was being treated at the Royal Sussex County Hospital

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

She said the report would require a response within 56 days and would be sent to the hospital trust, department heads, the Care Quality Commission (CQC) and other appropriate parties.

The coroner added that the public should “receive some reassurance” from the jury’s “vigorous” examination of the circumstances of Mrs Blaber’s death.

The inquest heard from staff nurse Alba Duran, who described how she poured liquid from a jug into a beaker so Mrs Blaber could take her medication.

Mrs Blaber started coughing and vomited twice in the minutes after she swallowed the fluid and was seen “frothing at the mouth” and “fighting for her breath” the next morning.

Relatives told the inquest that Mrs Blaber’s clear water jug was replaced with a solid green one which meant no-one could see the liquid inside.

The inquest heard that 14 months before Mrs Blaber’s death, staff had been told another patient had consumed toilet cleaner.

Housekeeper Daniel Gonzales told the hearing: “Apparently the patient, who had dementia or something like that, took it and drank it.

“It’s just a story, I’m not sure if it was true.”

He suggested the story may have been told to “worry” staff into taking safety measures at the hospital seriously.

During the course of the proceedings, it also emerged Flash was not even a “necessary” cleaning product for the hospital to stock and was merely used to make the building smell clean.

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