Scandal-hit Mid Staffordshire NHS Foundation Trust has been fined £200,000 over what the judge described as “a wholly avoidable and tragic death of a vulnerable patient”.
HSE prosecuted the trust after diabetic patient Gillian Astbury, 66, lapsed into a coma following a failure to administer her with insulin. She died of diabetic ketoacidosis in the early hours of 11 April 2007, 11 days after she was admitted to Stafford Hospital with fractures to her arms and pelvis sustained in a fall at home.
Stafford Crown Court heard how nurses on Ms Astbury’s ward did not follow, or sometimes even look at, her medical notes during up to eight shift changes and as many as 11 drug rounds.
The trust pleaded guilty to breaching section 3 of the Health and Safety at Work Act 1974 when it appeared before the court on 9 September. It was ordered to pay £27,049 in costs on top of the fine at sentencing on 28 April.
According to an internal investigation, the system for communicating patient needs at staff handovers was “inconsistent and sometimes nonexistent”. HSE’s report concluded Ms Astbury’s nursing and communication about her care “fell significantly short of what would be expected”.
Her notes prepared by the doctor that admitted her stated she needed insulin, regular blood tests and a special diet, and outlined medication to administer should her blood sugar levels test high.
Summing up, Judge Mr Justice Haddon-Cave outlined how the hospital’s management failed to “prescribe, monitor and enforce a proper, structured and rigorous system of work for handovers between nursing shifts and to devise and ensure the proper marshalling, updating and checking of medical records and notes”.
He added: “These failures of organisation and management meant that nursing and medical staff were working within a lax and poorly run system from the start... This was a wholly avoidable and tragic death of a vulnerable patient who was admitted to hospital for care, but who died because of the lack of it.”
In February 2013 Robert Francis QC published a damning report following his inquiry into standards of care at Mid Staffordshire NHS Foundation Trust. It spoke of “an engrained culture of tolerance of poor standards, a focus on finance and targets [and] denial of concerns”. HSE came in for criticism in the report, for what Francis felt was a “regulatory gap” between it and the healthcare regulator CQC.
“The trust’s systems were simply not robust enough to ensure staff consistently followed principles of good communication and record keeping,” said Peter Galsworthy, HSE’s head of operations in the west Midlands. “Gillian’s death was entirely preventable. She just needed to be given insulin.
“Gillian Astbury and her loved ones were failed by Mid Staffordshire NHS Foundation Trust. We expect lessons to be learned across the NHS to prevent this happening again.”
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