Mid Staffordshire NHS trust fined for "avoidable and tragic death"

Gillian Astbury died at Stafford hospital in 2007. Photograph: Rui Vieira/PA

The Mid Staffordshire NHS basis trust has been fined £200,000 and ordered to spend far more than £27,000 in expenses over what the judge described as “the wholly avoidable and tragic death of a vulnerable patient”.

The Overall health and Safety Executive brought an unprecedented criminal case against the believe in above the death of Gillian Astbury, 66, who died in 2007 due to the fact nurses at Stafford hospital failed to give her the program insulin she needed to remain alive.

The Francis inquiry into bad requirements of care at Mid Staffs looked in detail at the Astbury situation and criticised the HSE for an apparent inability to determine whether it should prosecute, despite the inquest jury’s findings that there had been a gross failure to give care. The HSE announced last August that it would bring the situation. In court, the trust pleaded guilty to an offence under the Wellness and Safety at Perform Act.

The court heard that health-related personnel did not comply with – and often did not even search at – Astbury’s healthcare notes, which plainly stated that she essential insulin, normal blood exams and a specific diet regime. Problems had been made as her ward underwent as a lot of as eight shift adjustments and 11 medicines rounds per day. The technique for handovers, when nurses arriving for the next shift ought to be informed of the demands of the individuals, was “inconsistent and at times non-existent”, the believe in admitted.

“Mid Staffordshire NHS basis trust failed to apply a correct handover technique, or to oversee the correct completion of nursing records and the monitoring of care ideas,” stated Peter Galsworthy, HSE head of operations in the West Midlands. “In performing so, they put Gillian Astbury at risk. The trust’s programs have been just not robust adequate to make sure that staff regularly followed concepts of very good communication and record retaining. Gillian’s death was completely preventable. She just essential to be provided insulin.

“Gillian Astbury and her loved ones were failed by Mid Staffordshire NHS foundation believe in. Each hospital patient has the right to expect much more. Significant security management flaws had been recognized by our investigation. We expect lessons to be learned across the NHS to avert this taking place once again.”

Astbury, who had been admitted to the hospital in 2007 due to the fact of fractures to her arm and pelvis, lapsed into a coma right after nurses failed to give her the insulin injections she needed to stay alive. Two nurses had failed to notice her high blood sugar levels – each have been disciplined and 1 was struck off by the Nursing and Midwifery Council final year.

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

“A important fine is referred to as for to reflect the gravity of the offence, the loss of a lifestyle and in purchase to send out a robust message to all organisations, public or private, accountable for the care and welfare of members of the public.”

Mid Staffordshire NHS trust fined for "avoidable and tragic death"