Joan Blaber

Fi'.l:~j 
Brighton and Sussex 
University Hospitals 
NHS Trust 

17 December 2018 

Miss Veronica Hamilton-Deeley 
HM  Senior Coroner for Brighton and  Hove 
The Coroner's Office 
Woodvale 
Lewes Road 
Brighton 
BN23QB 

Brighton and Sussex University Hospitals 
NHS Trust 
Trust Headquarters 
Royal  Sussex County Hospital 
Eastern Road 
Brighton 
BN25BE 

Dear Miss Hamilton-Deeley 

The late Joan Catherine Blaber 

Thank you for your letter of 2 October 2018 enclosing your report written  under Paragraph 7, 
Schedule 5 of the Coroner's & Justice Act 2009 and  Regulations 28 and  29  of the Coroner's 
(investigations) Regulations 2013,  and .the  Record  of Inquest. 

Mrs Blaber's inquest has truly resulted  in  a culture shift at the Trust,  with  substantial 
improvements in our systems and  processes;  some of which  you  are already aware of from 
our SI  report and  CQC  action  plan,  and  some new improvements in  addition,  of which  I will 
detail below. 

Control of Substances Hazardous to Health Regulations (COSHH) 

Every ward  and  department has a revised  and  up to dal:e  COSHH folder listing all  COSHH 
products, their proper usage,  risk  assessments,  and the COSHH guidelines. The CQC at 
their recent inspection confirmed they were impressed with  our COSHH folders and staff 
knowledge and  compliance in  relation to COSHH. 

Training 

,  Clinical Director for Fadlities and  Estates has confirmed that  our COSHH 
training  has been reviewed  and  updated.  Our training  includes anonymised extracts from 
evidence given  at Mrs Blaber's inquest to  ensure our staff can  actually relate to the content 
and  are aware of the seriousness of COSHH  products in  our hospitals. 

Roles 

I am  pleased to  say the roles of Hosts and  Housekeepers has been split and  clarified  as 
recommended  by you  at the inquest. We now have dedicated Catering Assistants who have 
no cleaning duties outside the kitchen.  Housekeepers are now tasked only with  cleaning 
duties and do not deal with  patients' food  or water.  These new clearer roles  have started in 
the  Barry Building,  Sussex Eye Hospital and th~ Nurse:·y and there is a roll  out programme 
in  progress so the whole of the Trust will  be  incorporaterl by the end of March 2019.  To 

 
 
 Brighton and Sussex 
University Hospitals 
NHS Trust 

make these distinct roles clearer for patients,  families,  visitors and  staff,  new uniforms have 
been ordered so the uniforms of the two distinct roles are not confused  and  are well 
differentiated.  Furthermore, the  management structure has been  updated.  Catering 
Assistants (Hosts) are  now managed by the  Food Safety Manager so they are not under the 
same managerial line as the Housekeepers. When each member of staff has moved across 
to the new management structure, there has been a review of the training they have 
received,  they have received  refresher training ..whether they were due this or not,  under their 
new management structure. The training  records are securely stored and  regularly reviewed 
to ensure training  is up to  date. 

Coloured jug system 

All  patient jugs are now clear so the contents can  been easily seen. All  opaque coloured jugs 
have been  removed from  use.  The training  our .staff have received  confirms that clear jugs 
are the only jugs to  be  used,  and they are  only to be  used for patients' drinking water. 

Agency staff 

Following  Mrs Blaber's inquest we have not employed any Agency Housekeepers or 
Catering Assistants.  It is our intention to remain  in this position  as there is a full  recruitment 
programme in  place to recruit permanent members of staff to  any vacancies. Any new 
members of staff will attend Trust Induction (no· matter what role they undertake)  and 
undertake the Trust's programme of statutory and  mandatory training (this portfolio includes 
Health and  Safety Training). All  Facilities and  Estates staff training is monitored  by the 
Facilities and  Estates Learning  and  Development Manager and kept in  date. 

Education and understanding 

Owing to the culture change brought about by Mrs Blaber's experience,  COSHH 
management is a regular agenda  item 011  many of our meeting agendas.  For example,  it is 
now routinely discussed at the Patient Led Assessments of the Care Environment (PLACE) 
meetings, the Weekly Operational Look Forward Meeting  and teams' safety huddles. Terece 
Walters is the Chair of the  Food  Improvement Group and  Ms Walters has ensured the group 
monitor and  maintain the systems and  processes we have put in  place and there is  a clear 
governance reporting escalation channel  up to the Executives and the Board, for any 
concerns.  The Head of Nursing for Practice Development has become a member of this 
Group, to ensure that learning  is spread  across the orga11isation  and any new initiatives are 
widely communicated to  all  groups of staff . 

 also designed a presentation  using the learning from  Mrs Blaber's inquest which 

.
she has delivered to  her teams and a wider audience,  being  open  and frank about what 
happened, the system failures and  our organisational  learning.  This presentation 
encourages staff to report any concerns about patient safety/ COSHH management 
immediately to their li.ne  manager and to  report it as an  incident on  Datix. 

Learning from  Mrs Blaber's inquest has  been  spread  (without using  names) throughout the 
Trust in a variety of mediums,  such as internal Newsletters,  daily team  huddles,  and 
debriefs. Teams discuss the use of COSHH products in their areas and  have a clear 
understanding of their roles  and  responsibilities in  relation to this and what is  acceptable 
practice. 

 ,~1:~j

Brighton and Sussex 
University Hospitals 
NHS  Trust 

I have been  assured that any breaches (however minor they may seem) are  recorded  on 
Datix and  investigated formally by the Facilities and  Estates Directorate and  our HR team; 
staff involved are removed from duty immediately and  receive retraining  during the 
investigation  process. Any actions identified as  necessary from the investigation are put in 
place and  monitored by the Senior Management team  in  Facilities and  Estates who  report 
actions and learning to the Health  and  Safety Committee. 

Cleaning Cupboards and  Cleaning Trollies 

.The Trust's cleaning  cupboards have been  modified now to  swipe card  access only to 
guarantee they are secure at all times and we have a record of who  has accessed the 
cupboards and when.  Only with  permission from 
 can  staff have their ID cards 
updated to include access to  a cleaning  cupboard.  The introduction of swipe card  access 
has meant we have significantly reduced the number of staff who have access to COSHH 
products and the staff who do have access have all  received the appropriate COSHH 
training.  This alone has made our hospitals much safer for patients,  visitors and  staff. 

There has been a review of our cleaning trollies and where we store the cleaning trollies. 
Now,  if trollies are not able to be stored  in  a locked cleaning  cupboard, for example,  if the 
space does not allow,  the trolley itself is  locked and there is  a sign identifying where the 
trolley's designated area when  not in  use is,  which  has been  risk assessed as  a safe place, 
and the trolley must be  returned to the designated are,'! when not in  use. 

 undertakes scheduled walks around the hm,pitals to  conduct environmental 

checks and  non scheduled checks too so she,  and  I,  can  be  assured that the correct safety 
standards are adhered to  in  relation to the safe storage and  use of COSHH  products 
throughout our hospitals. 

Learning from  incidents 

Following the inquest, 
ranging  appraisal of the Trust's Incident Reporting system. This piece of work is still  in 
progress, the preliminary recommendat,ons include: 

,  our Deputy Chief of Safety has commenced a wide 

•  A review of all  the existing specialty (i.e.  obstetrics,  paediatrics, etc.) and specialist 
interest Datix clinical  incident forms (i.e.  pressure ulcers, falls,  MET calls etc.) to 
provide assurance that the data currently captured is utilised,  and to  identify whether 
further information tailored to specific incidents should be  captured. 

The model for this recommendation ls the successfu1  programme of work on the incident 
reporting  of patient falls.  When  an incident report of a patient's fall is  submitted, the incident 
reporting  system generates a series of questions which facilitate the systematic review of 
trends and  patterns in  relation  to inpatient falls.  This information is collated monthly allowing 
ward  managers to compare their performance with the rest of the Trust and  identify issues 
that need to be addressed. 

The second recommendation  proposes: 

•  Reviewing the categorisation of clinicaLincidents. 

The taxonomy for categorising  patient safety incidents was developed over 15 years ago  by 
the National Patient Safety Agency, wt1ilst the categorisation  of incidents has evolved over 
the years,  it is  now in  need ofa major 1.werall,  removing those incident types that are not 

 Bris:,hton  and  Sussex 
University Hospitals 
NHS Trust 

used,  and developing incident descriptors that make it easier to visualise an  incident. 
Improving the coding will  have two benefits: 

1.  Easier for reporters to accurately code the incident they are reporting. 
2.  Better coding  should result in  better trend analysis. 

One of the challenges faced  is the exponential year on  year increase in  the number of 
clinical  incidents reported.  In the past 10 years the number of reported  incidents has more 
.than  doubled from  5,685 in  2008 to a projected  11,800 in  2018.  There is a paradox when  it 
comes to constantly increasing the number of incidents reported  in  that the time available to 
investigate and  share learning  is stretched  more tightly.  This reality makes the management 
of this information more critical,  the final  draft recommendation  is that the twelve thousand 
Datix incident reports received  each year need  a better methodology for analysing the data 
and that this  information  needs to  be more widely disseminated. As part of this proposal,  it 
has been suggested that Statistical Process Control  methodology is  piloted  at the Trust to 
see whether this approach  is helpful in  identifying unusual patterns and trends in  incident 
reporting.  It has also been  proposed that the number of clinicians receiving  data from  clinical 
incident reporting  needs to be widened and that this data should  also feed  into the Divisions, 
Directorates and  Speciality governance structures. 

As you  have said,  it is  unlikely that we will ever know how Flash  cleaning fluid got into Mrs 
Blaber's water jug, and I agree.  Howev~r.  I wish to rea$sure that we have discussed the 
tragic incident at very high level  meetings,  including our Board  Meetings and Trust Executive 
Committee meetings, to  ensure we have learnt and to embed this learning from  the top 
down, as well  as from the 'hands on'  Housekeepers and  Catering Assistants up,  and we 
continue to encourage an  open culture of iearnjng  at a.ii  levels. 

My heartfelt condolences and  a sincere apology go to Mrs  Blaber's family and friends. 

Chief Medical Officer and  Deputy Chief Executive