A jury at the inquest into the death of an elderly hospital patient who drank Flash floor cleaner left in a water jug by her bedside has criticised management and training at the Royal Sussex County Hospital in Brighton.
Joan Blaber died six days after drinking the fluid last year.
The 85-year-old, from Lewes, East Sussex, was admitted with a minor stroke on 22 August but her condition worsened after the incident on 17 September and she died on 23 September.
The jury of six women and three men left Brighton and Hove Coroner’s Court on Tuesday after more than two days of deliberations, returning on Thursday.
Senior coroner Veronica Hamilton-Deeley described Blaber as an “amazingly stoical lady” and 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 Blaber’s death.
Blaber’s family said in a statement read by their solicitor Jonathan Austen-Jones: “As a family we continue struggling to come to terms with what happened to Joan on September 17 last year.
“We have found the inquest both daunting and traumatic at times listening to the evidence.
“We wish to thank both the coroner and the police for conducting a thorough and wide-ranging investigation into the circumstances of Joan’s death and also the jury for the extremely diligent way they considered the evidence and the detailed conclusions reached.
“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.
“Finally we would like to thank our friends and family for their kindness and support over the last year.”