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A 85-year-old woman died after drinking cleaning fluid which had been put in a water jug as a result of "serious failings" at a hospital trust, a coroner has concluded.
Joan Blaber, from Lewes, East Sussex, died six days after drinking Flash cleaner at the Royal Sussex County Hospital in Brighton.
An inquest jury found there were "serious communication failures".
Mrs Blaber's family said they hoped the hospital trust "learns lessons".
Mrs Blaber was admitted with a minor stroke on 22 August and died on 23 September - six days after she drank the cleaning fluid from a water jug on her bedside table.
The jury at Brighton and Hove Coroner's Court concluded hospital staff were not monitored after training and adequate training was not given to agency staff.
Recording a narrative verdict, they said: "Inappropriate practices in the hospital were not addressed to to a culture of non-reporting.
"Evidence leads us to believe there was widespread confusion surrounding the water jug system that was in place and that jugs were being misused."
Management had missed an opportunity to learn and disseminate lessons from an incident in 2016 on the same floor in which another patient had drunk cleaning fluid, the jury said.
They added: "Serious communication failures in the hospital opened the way to misunderstanding of procedures, errors in practice and resulted in a failure to implement lessons that could have been learned.
"We found this contributed to Mrs Blaber's safety being compromised."
'Daunting and traumatic'
Coroner Veronica Hamilton-Deeley said she would be "requiring action to prevent other further possible deaths". The hospital has 56 days to respond to the coroner.
"The jury have recorded serious failings, they have identified and explored them and found them directly related to Joan's death," she added.
"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."
In a statement, Mrs Blaber's family said they had found the inquest "both daunting and traumatic".
"We continue struggling to come to terms with what happened to Joan.
"It is our sincere hope the hospital trust learns lessons and takes the appropriate remedial action to prevent another death in these circumstances.
"It should never have happened in the first place."
Nicola Ranger, chief nursing officer at the hospital, said: "I can say with certainty lessons have been learned, and that we have put in a full review of structures, processes and training, but as we know from an extensive police inquiry and from the coroner's court there are still some questions left a little bit unanswered."