A hospital trust has been criticised for “serious failings” that led to the death of an elderly patient as a result of drinking cleaning fluid. An Inquest into her death, held between 10th and 18th September 2018, has resulted in the issue of a Regulation 28 Report (Prevention of Future Death report) by the Coroner.
Mrs Joan Blaber was an 85 year old vulnerable patient who had been admitted to the Royal Sussex County Hospital on 22 August 2017 having suffered a minor stroke. Although Joan was not quite ready for discharge at the time of the tragic incident, she was making good progress and it was anticipated that she would be discharged within a few days.
At around 10pm on 17th September 2017 Joan ingested Flash floor cleaner which had somehow been put in a water jug, left on her bedside cabinet, and then subsequently used by a nurse to dilute some squash for Joan to take her medication with.
Sadly Joan died 6 days later on 23 September 2017 following a rapid deterioration in her health. Joan died of respiratory failure as a result of chemical pneumonitis (an inflammation of the lining of the lungs), which had been caused by the ingestion of the Flash floor cleaner.
The inquest was an Article 2 inquest, held with a Jury, enabling the coroner and jury to conduct a more wide-ranging investigation into the circumstances surrounding the death of Joan Blaber, with particular focus on the systems in place at the hospital regarding the storage of hazardous substances (Control of Substances Hazardous to Health Regulations 2002). Evidence was given in person by 18 witnesses, including hospital staff, family members and police officers, and a further 10 written statements were submitted in evidence.
Having heard all of the evidence and a detailed summing-up by the Coroner, the Jury returned a narrative conclusion (similar to a verdict) that:
“There was widespread confusion surrounding the water jug system that was in place, and that jugs were being misused”.
They also found that:
“Understanding and implementation of cleaning procedures were inconsistent and inadequate amongst agency and Trust cleaning staff.”
They added that “management failed to direct and monitor staff” and did not adhere to regulations relating to hazardous substances “leading to ongoing breaches”.
After the Jury had delivered the conclusion, the Senior Coroner for Brighton and Hove, Miss Veronica Hamilton-Deeley, criticised the Hospital Trust for the “serious failings” which had been identified by the Jury, and for not learning any lessons from a previous similar incident at the same hospital in July 2016. She stated that she would be writing to the Brighton and Sussex NHS Trust in the form of a Regulation 28 Report, which will set out the steps she believes should be taken to prevent any future deaths in these circumstances, saying:
“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.”
Jonathan Austen-Jones, Solicitor for the Blaber family, said:
“The central theme running through the Inquest evidence was poor communication in the hospital from top to bottom. In various ways this combined to create a catalogue of errors which contributed to Joan’s death. The poor communication systems were reflected in staff training, the safe storage of hazardous substances and a coloured water jug system which was not understood by the majority of staff. Joan was given the wrong jug, one that was solid green and opaque, meaning that the nurse could not see the contents. Had she been given the correct transparent jug, it is most likely that Joan would be alive today.
We also heard evidence that the cleaning staff, including duty managers and supervisors, acted in contravention of regulations which should be in place for the safe storage of hazardous substances. We heard evidence that there is an overlap in the jobs carried out by the cleaners and the kitchen assistants. On this day in question the cleaners were also replacing and replenishing the water jugs.
Probably what has been most concerning and upsetting for Joan’s family is that towards the end of the Inquest evidence we learned of a previous similar incident which happened only 14 months before Joan’s. The full facts are unclear as to exactly what happened but we do know that fortunately that patient didn’t die or suffer any serious harm, as far as we know. The hospital recorded the incident as a near miss. The Coroner referred to this incident as a missed opportunity to learn from it.
I would suggest that it should have been a wake-up call for senior management to rectify the failings in the system; instead it was treated as a minor incident and only the cleaner concerned was spoken to. Had the hospital reviewed their procedures and learned from this near miss, Joan’s death could well have been avoided.
Although it provides some reassurance that the hospital is taking this matter seriously and will be implementing changes to their systems, it is extremely disappointing that it has taken a patient’s death in these circumstances to prompt action. Tragically for Joan, changes have come too late.”