NHS Trust admonished after death of elderly woman who swallowed cleaning fluid
Health inspectors have told a hospital trust it must do more to protect patients after an elderly woman is thought to have accidentally swallowed cleaning fluid and died.
The Chief Inspector of Hospitals said Brighton and Sussex University Hospitals NHS Trust must take further steps to protect people in its care from potentially hazardous cleaning materials, the Care Quality Commission (CQC) said.
It comes after Joan Blaber died on September 23 while being treated at the Royal Sussex County Hospital in Brighton.
The 85-year-old from Lewes, East Sussex, had reportedly been drinking a cup of orange cleaning liquid which had been mistaken for juice.
Police investigated her death, interviewing scores of staff, but said they found no evidence of a crime being committed. An inquest is due to take place in September.
CQC inspectors visited several of the hospital’s wards unannounced in October.
As the report was published on Thursday, the health watchdog said that after viewing trust training materials during the inspection it was clear there was “no legitimate reason to decant cleaning products into other containers”.
The CQC said: “Although staff were aware of this, some cleaning staff said there had been occasions where this had happened without authorisation.”
Inspectors also expressed concern that nursing staff had been trained in Control of Substances Hazardous to Health (CoSHH) rules but not all understood their responsibilities.
The regulator said cleaning trolleys with hazardous substances were found unattended during the inspection, products were sometimes stored in unlocked rooms or key codes were written near the locks on storage rooms.
Paperwork was not always complete or available.
But housekeeping staff were retrained recently and had a good knowledge of the regulations on using cleaning products, the report added.
Amanda Stanford, a CQC deputy chief inspector of hospitals, said: “The regulations governing the safe use of these cleaning products are there to protect people from harm. During our inspection we found that these chemicals were not always being kept safely.
“We have told the trust they must ensure all products that are subject to the regulations are stored securely. They must also introduce a system which gives assurance that information relating to all substances subject to Control of Substances Hazardous to Health is available in every work area.
“This information must be complete and accurate, and staff must be able to understand it. Nursing staff too must be aware of the regulations and their responsibilities with regard to safe storage and use of these products.”
The trust must now show how it will meet the regulations and inspectors are to return soon to check improvements have been made.
Dr Rob Haigh, the trust’s medical director, said: “The incident was reported straight away and we took immediate, trust-wide action to prevent the same thing happening again.
“In the seven months since the CQC’s inspection, we have taken significant steps to improve the way we manage potentially hazardous substances both in terms of staff training and the way these substances are stored and used, addressing the points published in today’s report.”
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