The devastated family of Lewes pensioner Joan Blaber have urged a Brighton hospital trust ‘to learn lessons’ following her death after drinking cleaning fluid.
Today (September 20) a jury concluded that the 85-year-old died of respiratory failure, caused by pneumonia and chemical pneumonitis, as a result of drinking cleaning fluid at the Royal Sussex County Hospital.
The jury found that failings by the hospital led to ‘Mrs Blaber’s safety being compromised’.
Related stories: Cleaning fluid hospital death ‘could happen again’
The conclusion said: “On September 17 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 whilst 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 amongst agency and Trust cleaning staff.
“Furthermore we find that management failed to direct and monitor staff, adhere to and enforce the control of substances hazardous to health regulations, leading to ongoing breaches of regulation.
“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 database.
“Based on this evidence we find this contributed to inappropriate practices in the hospital, which were not addressed due to a culture on 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.”
Senior coroner for Brighton and Hove Veronica Hamilton-Deeley said the incident has ‘had a devastating effect on her family and many friends, and on the staff of all levels at the Brighton and Sussex University Hospitals NHS Trust and Royal Sussex County Hospital’.
She said: “The jury have recorded serious failings. They have identified and explored them and found them to be directly related to Joan’s death.”
She said she would write a report to the hospital trust, CQC and health and safety executive, ‘requiring action to prevent other further possible deaths’
A statement read on behalf of the family said: “As a family, we continue struggling to come to terms with what happened to Joan on 17 September last year.
“We have found the Inquest both daunting and traumatic at times listening to the evidence.
“We wish to thank both the Coroner and the Police, for conducting a thorough and wide-ranging investigation into the circumstances of Joan’s death and also the Jury for the extremely diligent way they considered the evidence and detailed conclusions reached.
“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 that 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.”
Mrs Blaber, 85, of Hoopers Close, Lewes, died at the Royal Sussex County Hospital on September 23, 2017, six days after ingesting Flash cleaning fluid which was in a green water jug by her bed.
The jury heard that cleaning fluids were stored in cupboards, but they were not always locked and sometimes had the code written nearby.
At the start of the two-week inquest at the Jury’s Inn Brighton, coroner Miss Hamilton-Deeley told warned that it ‘could happen again’ as ‘no-one could actually say what happened’ to Mrs Blaber.
Mrs Blaber was recovering from a minor stroke at the hospital.
After ingesting cleaning fluid mixed with a summer fruits cordial on September 17, 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.
After a post mortem, a pathologist said Mrs Blaber died of respiratory failure as a result of pneumonia after the ingestion of cleaning fluid.
The inquest heard the police were not informed of the incident until eight days after, and although they interviewed 100 people, Detective Inspector Julie Wakeford said there was no evidence of criminal action.
Nicola Ranger, chief nurse at Brighton and Sussex University Hospitals NHS Trust, said: “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.”