Trust ordered to improve storage of dangerous liquids after patient death

Inspectors found unattended cleaning fluids, codes to access secure cupboards written on doorframes and evidence that staff brought in cleaning materials from home, at Royal Sussex County Hospital in Brighton.

The Care Quality Commission made an unannounced visit to the hospital in October, a month after 85 year old Joan Blaber died. It is thought a staff member unintentionally gave her cleaning fluid, which had been decanted into a water jug. The CQC report said green jugs were subsequently replaced by clear ones across the hospital.

The inspectors found housekeeping assistants had a good knowledge of the Control of Substances Hazardous to Health regulations. However, they raised concerns including:

• There was no assurance that training around handling chemicals was effective. Staff questioned by inspectors could not say what safety data sheets and risks assessments were used for or where they were kept.
• The trust said key codes to assess cleaning cupboards had been changed but that had not happened at the time of the inspection. In three cases, access codes were written on the door or doorframe.
• On some wards, cleaning products did not fit into cleaning trolleys and in some cases trolleys were left unattended or cleaning fluids were in unlocked storage areas.
• Some products subject to regulations had been purchased outside the trust’s procurement process and had no safety data sheets or risk assessments. A staff member brought a bottle of bleach in from home and put it in a ward kitchen.
• Although there was no legitimate reason to decant cleaning products into other containers, there were instances when it happened and the management team had heard this had happened.

Amanda Stanford, CQC deputy chief inspector of hospitals for the South, 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 CoSHH regulations are stored securely. They must also introduce a system which gives assurance that information relating to all substances subject to CoSHH 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.”

Rob Haigh, medical director of Brighton and Sussex University Hospitals Trust, said: “Our thoughts are with the patient’s family. The incident was reported straightaway and we took immediate trust wide action to prevent the same thing happening again. In the seven months since the inspection, we have taken significant steps to improve the way we manage potentially hazardous substances both staff training and the way the substances are stored and used, addressing the points in today’s report.”

An inquest into Ms Blaber’s death is expected later this year.

The hospital was ordered to ensure that all CoSHH products were stored securely, ensure information about these products was complete and that staff understood it, and ensure nursing staff were aware of their responsibilities under the regulations.