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 the Royal Sussex County Hospital in Brighton last year.
The 85-year-old, from Lewes, East 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 on Wednesday, a jury returned a narrative conclusion stating: "Evidence leads us to believe there was widespread confusion surrounding the water jug system that was in place and that jugs were being misused."
Mrs Blaber’s clear 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.
The jury said: "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 (COSHH) leading to ongoing breaches of regulation."
They continued: "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."
Senior coroner Veronica Hamilton-Deeley said she would be writing to the Brighton and Sussex University Hospitals NHS Trust in the form of a Regulation 28 report to prevent further deaths.
She said: "The jury have recorded serious failings, they have identified and explored them and found them directly related to Joan’s death and in the light of this I shall be making a Regulation 28 report.
"This is a report requiring action to prevent other further possible deaths.
"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 eight-day 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, the court was told.
The hospital’s system of using different types of water jugs to identify the needs of patients was a "complete red herring" because it was "abundantly clear that no-one (ward staff) had any idea about the system of the jugs", Mrs Hamilton-Deeley said.
Staff nurse Alba Duran described how she poured liquid from a jug into a beaker so Mrs Blaber could take her medication at about 10pm.
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.
Ms Duran found a five-litre 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.
On the day of the incident the store was left unlocked, housekeeper Olga Thomasa told the inquest.
Concerns were raised over plans for reporting incidents, as it emerged police were not told about the incident until eight days later.
This hugely affected the chance to gather forensic evidence, the inquest heard.
Despite an investigation in which 100 people were interviewed, officers found no evidence the incident was a malicious act but have been unable to rule this out completely.
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.
What is more, Ms Hamilton-Deeley criticised the trust over an "extremely misleading" letter it sent out to public figures ahead of the inquest over fears about press coverage that would result from it, branding it a "worrying matter".
She expressed concern that some paragraphs contained inaccurate information, or could alternatively suggest testimony given under oath was wrong.
Ms Hamilton-Deeley said the note implied the incident was reported immediately to the police, when in reality, the inquest was told, officers were not contacted until eight days later, affecting their ability to collect forensic evidence.
Housekeeping checks which review how chemicals are stored were now carried out on a daily basis, according to the letter, but evidence from trust staff confirmed these were not carried out to the same extent on weekends, which was significant because the incidents in question occurred on a Sunday, Mrs Hamilton-Deeley said.
She said the "disrespectful" letter - sent to local politicians, civic leaders and health chiefs - made the inquest sound like the coroner was hosting a "tea party" rather than a formal judicial inquiry.
Clare Hennessey, representing the trust, said the letter was a bid to offer reassurance and be "open and transparent", and that it was "absolutely committed" to ensuring nothing like the incident involving Mrs Blaber ever happened again.
This was the third time the coroner had hit out at the trust during the inquest for not disclosing information, something the family's legal team described as "missed opportunities".
In this third incident, the trust's own lawyer was not told about the letter. It only emerged when passed to the coroner anonymously amid jury deliberations.
Ms Ranger, chief nurse at the trust, said: "I don't believe it was a mistake releasing that letter but I do believe we should have shared that with the coroner.
"All we did with our interested parties was alert them that this inquest was going to be taking place so that if any of their constituents or local public spoke to them about it, they were fully informed the inquest was taking place."
Speaking after the inquest, the solicitor for Mrs Blaber's family, Jonathan Austen-Jones, said it was "inappropriate to comment" on the possibility of legal action against the hospital trust.
Reading a statement on behalf of the family, he said: "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."
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."
Ms Ranger added that "after the incident, our clinical staff gave exemplary care to try and do their best for Mrs Blaber and also after the incident we took immediate action to remove all green jugs.
“We have done a lot of work with our systems, processes and training since then, so I am confident that an incident like that won’t happen again.”
The inquest heard Flash had been left in an unlocked cupboard, and Ms Ranger said: “We have put in new cupboards, we have put in a new swipe access so we can see both who goes in and out of cupboards and that the doors are then secure.
“We have bought lockable cleaning trolleys and one of the most important things is we have improved and increased training for staff and there is greater vigilance.”
Ms Ranger also said the trust had shared information about a previous incident involving a cleaning product being ingested at the hospital and had improved training.