Cleaning fluid hospital death '˜could happen again'
An incident which saw an elderly woman die six days after drinking cleaning fluid at a Brighton hospital '˜could happen again', a coroner warned today (September 10).
Brighton and Hove senior coroner Veronica Hamilton-Deeley told a jury its job was to ascertain how 85-year-old Lewes woman Joan Blaber died.
But she said that ‘no-one could actually say what happened’ and that police were not informed of the incident until eight days later.
Mrs Blaber, a retired shopkeeper and widow of Hoopers Close, died at the Royal Sussex County Hospital on September 23 last year. She was admitted to hospital on August 22 after suffering a minor stroke.
The inquest heard Mrs Blaber was given a drink which contained cleaning fluid mixed with a summer fruits cordial on September 17.
The cleaning fluid was in a ‘solid green’ jug, the inquest heard – which was one that was given to dementia patients under the hospital’s jug system – but that Mrs Blaber would usually be given a jug with a blue lid.
She became unwell and was taken to the intensive care unit the following day, before returning to an acute ward one day before her death.
In a post-mortem examination the cause of death was recorded as respiratory failure as a result of pneumonia after the ingestion of cleaning fluid.
Dr Philip Thompson, a stroke consultant at the Brighton and Sussex University Hospital Trust (BHUS), which runs the Royal Sussex County Hospital, addressed the inquest today, and read from the nurse’s notes taken on the evening of September 17, when Mrs Blaber is thought to have ingested the cleaning fluid.
The notes said Mrs Blaber became unwell at 10.25pm after taking her medication.
In the notes it said the nurse had then noticed ‘the jug on the bedside table which contained green liquid’ and that ‘it was not noticeable’ because the jug was also green.
The nurse wrote that Mrs Blaber was given around 15ml of the liquid, and said: “I only put a little drop on the top of some summer fruits to take her medication.”
After drinking the fluid, Mrs Blaber was given water and oxygen, Dr Thompson said, and seemed to stabilise, but was being checked on every hour throughout the night.
But at midday the following day she was admitted to the intensive care unit (ICU).
She returned to the stroke ward on September 22, after being transferred from ICU at around midnight.
Dr Thompson said her notes at the time of transfer showed she was ‘stable’, but said he saw her the following morning at around 9.45am when she was unwell.
“She did deteriorate quickly,” he said.
Mrs Blaber died the following day, on September 23.
The inquest heard from Detective Inspector Julie Wakeford of Sussex Police, who explained that police were only informed of the incident on September 26.
DI Wakeford said tests on the liquid in the jug – which had been preserved – did not conclusively show that the liquid was the Flash floor cleaner used at the hospital, but that both substances ‘contained the same parts’.
She added: “It was eight days after the event we were notified, forensically there was nothing else they could do.”
More than 100 people were interviewed as a result of the police investigation, and CCTV from the hospital was obtained, but DI Wakeford said there had been no criminal action as a result.
On how the jug came to be by Mrs Blaber’s bed, DI Wakeford said: “We believe it was placed there by one of the housekeepers after lunch.”
This is when the jugs are changed, washed and refilled, the inquest heard.
“The family noticed it was a different colour jug as they commented on it,” DI Wakeford said. “The family had only just given Joan a drink from the previous jug. And next time, as far as we know, that some one touched the jug, was 10pm when the medication was given.”
Miss Hamilton-Deeley said: “That might have raised questions about people knowing about the jug system, questions about how the jugs are washed and cleaned, and how the housekeeping staff know which bedside tables to put them on. And questions about how the cleaning fluids are stored.”
The inquest heard Mrs Blaber had suffered a minor stroke before being admitted to the Royal Sussex County Hospital on August 22.
She had been discharged from the Lewes Victoria Hospital, also known as Meadow Lodge, on August 21 after being treated there for pain from August 10.
Mrs Blaber had suffered from leg ulcers, arthritis and cancer, and was on a variety of medications.
The inquest, which is exepected to last ten days, continues.