The Press and Journal (Aberdeen and Aberdeenshire)
Hospital blamed for floor-cleaner death of woman
Inquest: Water jug on bedside table contained Flash
A coroner has hit out at the “serious failings” of a hospital trust following the death of a patient who died after drinking Flash floor cleaner which was put in a water jug on her bedside table.
Joan Blaber died six days after drinking the fluid at Royal Sussex County Hospital in Brighton last year. The 85-year-old, from Lewes, Sussex, was admitted with a minor stroke on August 22 but her condition worsened after the incident on September 17 and she died on September 23.
At Brighton and Hove Coroner’s Court, a jury returned a narrative conclusion stating: “There was widespread confusion surrounding the water jug system in place and jugs were being misused. Understanding and implementation of cleaning procedures were inconsistent and inadequate amongst agency and cleaning staff.
“We find 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 disseminate lessons from a 2016 incident on the same floor.”
Senior coroner Veronica Hamilton-Deeley said the public should “receive some reassurance” from the jury’s “vigorous” examination of the circumstances.
The inquest heard Mrs Blaber was a “chatty, lovely lady” who could have lived for another “couple of years”.
But she was the second patient to drink cleaning fluid at the hospital after a “near miss” just 14 months earlier.
Her clear-glass water jug had been removed part-way through the afternoon and was replaced with a solid green jug when returned, meaning no one could see the liquid inside.
Nurse Alba Duran said she poured liquid from a jug into a beaker so Mrs Blaber could take her medication at 10pm. Mrs Blaber started coughing and vomited twice in the minutes after she swallowed the fluid and was “frothing at the mouth” and “fighting for her breath” the next morning.
Ms Duran found a container of Flash propped behind a trolley in an open cupboard just metres from Mrs Blaber’s bed.
According to hospital protocol, the Flash should have been locked inside a nearby storage room with other chemicals.Police found no evidence the incident was a malicious act but have been unable to rule this out.
Nicola Ranger, chief nurse at Brighton and Sussex University Hospitals NHS Trust, said: “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.”