Hospital Trust’s basic failures led to patient’s death

A vulnerable diabetic patient died because a hospital trust failed to implement basic handover procedures and ensure essential record-keeping, a court has heard.

Staff at Stafford Hospital did not follow – sometimes even look at – medical notes that clearly stated Gillian Astbury needed insulin, regular blood tests and a special diet.

A system for communicating patient needs at staff handovers was ‘inconsistent and sometimes non-existent’ the trust itself admitted. Record-keeping and monitoring of patient care plans were also far below acceptable standards.
Specific to the care of Ms Astbury, 66, a Type 1 diabetic, mistakes were made at up to eight shift changes and as many as 11 drugs rounds. The failure to administer insulin was the direct cause of her death.

The Health and Safety Executive investigated, in line with its policy to investigate deaths that occur in the health sector where there is evidence that clear standards have not been met because of a systematic failure in management systems.

Mid Staffordshire NHS Foundation Trust was prosecuted by HSE and pleaded guilty to an offence under the Health and Safety at Work etc Act. At Stafford Crown Court, it was today fined £200,000 and ordered to pay £27,049 costs.

An HSE Inspector commented:“ Mid Staffordshire NHS Foundation Trust failed to implement a proper handover system, or to oversee the proper completion of nursing records and the monitoring of care plans. In doing so they put Gillian Astbury at risk. The Trust’s systems were simply not robust enough to ensure that staff consistently followed principles of good communication and record keeping. 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. Every hospital patient has the right to expect more. Serious safety management flaws were identified by our investigation. We expect lessons to be learned across the NHS to prevent this happening again.”

Mr Justice Haddon-Cave said:
“It was a wholly avoidable and tragic death of a vulnerable patient admitted to hospital for care but who died because of a lack of it.”

He added: “A significant fine is called for to reflect the gravity of the offence, the loss of a life and in order to send out a strong message to all organisations, public or private, responsible for the care and welfare of members of the public.”