Joan Blaber

I am Veronica HAMILTON-DEELEY, Senior Coroner, for the City of Brighton and Hove

On 14th November 2017 I commenced an investigation into the death of Mrs. Joan Catherine BLASER. The investigation concluded at the end of the inquest on 20th September 2018. The conclusion of the inquest was as per the attached NARRATIVE CONCLUSION

See Record of Inquest

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: – Historic and ongoing failure to comply with Control of Substances Hazardous to Health Regulations (COSHH) Failures in training (both Trust and Agency Staff) and in particular to ensure that training has been understood and retained. Confusion in roles. Mixing the roles of the cleaners with those members of staff who should only be dealing with food and water. Failure to communicate important practices/protocols eg. water jug system. Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. Failures in supervisory staff in the housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg. Giving Agency Staff a container of Flash to take away. Blatent breach of COSHH Failure to encourage reporting of suboptimal and dangerous practices within the hospital. Failure to identify “near miss” events, to disseminate these and to learn from previous mistakes.

In my opinion action should be taken to prevent future deaths and I believe you AND your organisation have the power to take such action.