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, originally from Tidworth, 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.

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.

“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.

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 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.

The jury at the inquest into the death of 85-year-old Joan Blaber criticised management and training at the Royal Sussex County Hospital in Brighton.

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.

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.”