PFD report

Mrs. Joan Catherine BLABER · Prevention of Future Deaths report

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Issued 1 Oct 2018•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
12

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised12

  1. Failure to monitor Trust staff after training
  2. Failure to encourage reporting of suboptimal and dangerous practices
    Part of recurring concern: Unreliable reporting of patient-safety incidents
  3. Failure to disseminate near-miss events
    Part of recurring concern: Failure to reliably disseminate contextualised safety learning to relevant staff
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. Action

    Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024.
  2. Action

    Secure cleaning cupboards with swipe-card access, restrict access to authorised trained staff and retain access records.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.
  3. Action

    Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to monitor Trust staff after training

Wider context from the report

“(5) Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to encourage reporting of suboptimal and dangerous practices

Wider context from the report

“(7) Failure to encourage reporting of suboptimal and dangerous practices within the hospital. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to disseminate near-miss events

Wider context from the report

“(8) Failure to identify "near miss" events, to disseminate these and to learn from previous mistakes. ”

Is this part of a recurring concern?

Yes — Failure to reliably disseminate contextualised safety learning to relevant staff.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to control provision of hazardous substances to agency staff

Wider context from the report

“(6) 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. Blatant breach of COSHH ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to communicate important practices and protocols

Wider context from the report

“(4) Failure to communicate important practices/protocols eg. water jug system. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain separation of cleaner and food-and-water handling roles

Wider context from the report

“(3) Confusion in roles. Mixing the roles of the cleaners with those members of staff who should only be dealing with food and water. ”

Is this part of a recurring concern?

Yes — Inadequate food-hygiene controls in care settings.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to identify near-miss events

Wider context from the report

“(8) Failure to identify "near miss" events, to disseminate these and to learn from previous mistakes. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide effective training for Trust and agency staff

Wider context from the report

“(2) Failures in training (both Trust and Agency Staff) and in particular to ensure that training has been understood and retained. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of Housekeeping supervisors to adhere to required practices

Wider context from the report

“(6) 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. Blatant breach of COSHH ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to learn from previous mistakes

Wider context from the report

“(8) Failure to identify "near miss" events, to disseminate these and to learn from previous mistakes. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of control over hazardous-substance training for agency staff

Wider context from the report

“(5) Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to comply with COSHH requirements

Wider context from the report

“(1) Historic and ongoing failure to comply with Control of Substances Hazardous to Health Regulations (COSHH) ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.

Verbatim wording from the response

“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 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 the Nursery and there is a roll out programme in progress so the whole of the Trust will be incorporated by the end of March 2019. To”

Source location

Response from Brighton and Sussex University Hospitals
Page 1 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Secure cleaning cupboards with swipe-card access, restrict access to authorised trained staff and retain access records.

Verbatim wording from the response

“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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 3 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.

Verbatim wording from the response

“████████ 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 line manager and to report it as an incident on Datix.”

Source location

Response from Brighton and Sussex University Hospitals
Page 2 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update COSHH training and use anonymised inquest learning to strengthen staff understanding of hazardous-substance risks.

Verbatim wording from the response

“████████, Clinical Director for Facilities 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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 1 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remove opaque coloured patient jugs and require clear jugs exclusively for patients’ drinking water.

Verbatim wording from the response

“All patient jugs are now clear so the contents can be 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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 2 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Appraise the Trust incident-reporting system and develop preliminary recommendations for improving incident data capture and analysis.

Verbatim wording from the response

“Following the inquest, ████████, our Deputy Chief of Safety has commenced a wide ranging appraisal of the Trust’s Incident Reporting system. This piece of work is still in progress, the preliminary recommendations include:”

Source location

Response from Brighton and Sussex University Hospitals
Page 3 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Move Catering Assistants into the Food Safety Manager’s reporting line and provide refresher training when staff transfer, with training records securely maintained and reviewed.

Verbatim wording from the response

“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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 2 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit permanent Facilities and Estates staff, avoid agency Housekeepers and Catering Assistants, and require Trust induction and statutory and mandatory training for new staff.

Verbatim wording from the response

“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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 2 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Record and formally investigate COSHH breaches, remove involved staff from duty during investigations, provide retraining and monitor resulting actions and learning.

Verbatim wording from the response

“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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 3 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct scheduled and unscheduled hospital environmental checks on COSHH storage and use.

Verbatim wording from the response

“████████ undertakes scheduled walks around the hospitals 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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 3 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss the incident at Board and Executive Committee meetings and continue promoting an open culture of learning across the Trust.

Verbatim wording from the response

“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. However, I wish to reassure 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 learning at all levels.”

Source location

Response from Brighton and Sussex University Hospitals
Page 4 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain revised COSHH folders in every ward and department, including product listings, usage guidance, risk assessments and guidelines.

Verbatim wording from the response

“Every ward and department has a revised and up to date 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.”

Source location

Response from Brighton and Sussex University Hospitals
Page 1 · response
Published 23 February 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Embed COSHH management in operational meetings and safety huddles, with Food Improvement Group monitoring, governance escalation and organisation-wide communication of learning.

Verbatim wording from the response

“Owing to the culture change brought about by Mrs Blaber’s experience, COSHH management is a regular agenda item on 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. Terence 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 organisation and any new initiatives are widely communicated to all groups of staff.”

Source location

Response from Brighton and Sussex University Hospitals
Page 2 · response
Published 23 February 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Lock cleaning trolleys when cupboards are unavailable, risk-assess designated storage locations and require trolleys to be returned after use.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2024.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Lock cleaning trolleys when cupboards are unavailable, risk-assess designated storage locations and require trolleys to be returned after use.

Verbatim wording from the response

“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 area when not in use.”

Source location

Response from Brighton and Sussex University Hospitals
Page 3 · response
Published 23 February 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026