The chief nurse of Brighton and Sussex University Hospitals NHS Trust has apologised after an inquest found “errors in practice” had led to an 85-year-old patient drinking cleaning fluid and dying.
Nicola Ranger assured lessons had been learnt and processes had been put in place in a bid to prevent a similar incident happening again.
“Serious communication failures in the hospital opened the way to misunderstanding of procedures”
Joan Blaber died six days after ingesting the hazardous liquid at The Royal Sussex County Hospital in Brighton.
An inquest into her death heard Ms Blaber was admitted to the hospital on 22 August, 2017 with symptoms of minor strokes.
On 17 September the same year, Ms Blaber’s clear water jug at her bedside was replaced with a solid green one containing a cleaning fluid. A staff nurse later used this jug to fill up a cup and gave it to Ms Blaber to drink with her medication.
The jury at the inquest at Brighton and Hove coroner’s court found there was “widespread confusion” around the water jug system and that cleaning procedures were “inconsistent and inadequate”.
Managers failed to enforce “control of substances hazardous to health regulations”, it noted.
“We are sorry, we have learned and we will continue to make every effort to improve”
The jury said leaders had also missed an opportunity to learn from a similar incident on the same floor of the hospital in 2016 involving the drinking of cleaning fluid.
It concluded: “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.”
The inquest closed on Wednesday.
Chief nurse Ms Ranger has issued a statement on the case.
She 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.
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“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.”