A vulnerable diabetic patient died, in a ‘wholly avoidable’ incident when staff failed to implement basic handover procedures and ensure essential record-keeping, a court has heard.
Gillian Astbury, 66, a Type 1 diabetic, died at Stafford hospital following ‘serious safety management flaws’, which meant that she was not given the insulin she needed.
Staff at Stafford Hospital did not follow — sometimes even look at — medical notes that clearly stated she 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, 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 HSE 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 this week (28 April) fined £200,000 and ordered to pay £27,049 costs.
Peter Galsworthy, HSE Head of Operations in the West Midlands, said: “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.”
At court today, 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.”
Jeff Crawshaw, deputy chief executive of Mid Staffordshire NHS Foundation Trust, said: “On behalf of the Trust, I want to again express our deepest and most sincere apologies to Mrs Astbury’s family for the unacceptable care she received at Stafford Hospital in 2007.
“Today marks the final stage in what has been a thorough and long running investigation into the failings which led to her tragic death.
“From the very beginning, we have acknowledged the failings in Mrs Astbury’s care, and we have never shied away from our responsibility for what happened to her.
“It has been recognised by all sides in this distressing case that our Trust is a very different and much better organisation now than it was when this tragedy occurred.”
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