Evidence at the Inquest was heard over 6 days between 10 and 18 September 2018. Evidence was given by 18 witnesses in person from a range of hospital staff, the family and the Police and a further 10 written statements were submitted in evidence.
This was an Article 2 Inquest held with a Jury. Article 2 had been engaged in this case which allowed the Coroner and the Jury to conduct a more wide-ranging investigation into the circumstances of what happened and “by what means and in what broad circumstances” Joan came by her death. Article 2 of ECHR means there is a positive duty to protect each individual’s life and includes a general duty to put in place – in this instance a hospital – systems to ensure that substances hazardous to health are stored correctly (COSHH Regulations 2002).
Joan 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 as she had a couple of health issues to be sorted out, she was making good progress and it was anticipated that she would be discharged within a few days, had the tragic incident on 17 September 2017 not happened.
At around 10pm Joan ingested Flash floor cleaner which had somehow been put in a water jug which had been left on her bedside cabinet and which a nurse then used 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 which was caused by a chemical pneumonitis (an inflammation of the lining of the lungs) which had been caused by the ingestion of the Flash floor cleaner.
Having heard all of the evidence and a detailed summing up by the Coroner, the Jury deliberated the issues over the course of 2 days and returned a narrative conclusion (similar to a verdict) and the conclusion of the Jury as to the cause of Joan’s death was as follows;
“Joan Catherine Blaber died 6 days after ingesting cleaning fluid on 17 September 2017 in the following circumstances.
Mrs Blaber was admitted to the Royal Sussex County Hospital on 22nd August 2017, with symptoms of minor strokes.
By the 7th September 2017, she was making progress, and doctors were considering discharge options. But general frailty and health issues meant she was unable to be discharged.
On the 17th September 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 (COSHH), leading to ongoing breaches of regulation.
In house training for Facilities and Estates was not optimised, due to the failure to monitor post training practices adequately. Training was also not guaranteed to the same standard for agency staff.
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 Incident Database.
Based on the evidence, we find this contributed to inappropriate practices in the hospital, which were not addressed due to a culture of 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.”
HM Coroner criticises hospital for “serious failings”
After the Jury had delivered the conclusion, the Senior Coroner for Brighton and Hove, Miss Veronica Hamilton-Deeley, hit out at the “serious failings” of the Hospital Trust which had been identified by the Jury.
The previous similar incident (which also happened on a Sunday) in July 2016 was a missed opportunity to learn from it.
The Senior Coroner said following the conclusion of the Inquest that she would be issuing what is known as a Regulation 28 Report which she would send to the Hospital Chief Executive which will set out what steps she believes should be taken to prevent any future deaths in these circumstances.
Due to the tragic and extraordinary circumstances of this case it understandably received a lot of press coverage. Click here http://www.itv.com/news/2018-09-20/coroner-warns-of-serious-failings-after-death-of-woman-who-drank-flash-cleaner/
A full copy of the family’s statement released following the Inquest can be read here [link to family’s statement].
The Blaber family were represented by Helen Pooley, Counsel, of 9 Gough Square Chambers.