Gillian Astbury death: Mid Staffordshire NHS Trust fined over patient death
The health trust which ran Stafford Hospital has been fined £200,000 for failing a diabetic patient who died in its care.
Gillian Astbury, 66, lapsed into a coma at Stafford Hospital after nurses failed to give her insulin. She died there in April 2007.
Mid Staffordshire NHS Foundation Trust admitted health and safety breaches.
A judge at Stafford Crown Court said Ms Astbury's death was tragic and wholly avoidable.'Routine' neglect
An inquest in 2010 ruled there had been a failure to provide basic care for Mrs Astbury who died after being admitted for fractures to her arm and pelvis.
End Quote Mr Justice Haddon-Cave
This was a wholly avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it”
Two nurses, Ann King and Jeannette Coulson, did not notice her high blood sugar, and she fell into a diabetic coma.
Ms King was subsequently struck off and Ms Coulson was cautioned after a Nursing and Midwifery Council panel found them guilty of misconduct last year.
At Stafford Crown Court, the Trust, which was also ordered to pay £27,000 in costs, pleaded guilty to breaching health and safety law.
Sentencing, Mr Justice Haddon-Cave said responsibility for the failures at the time of Mrs Astbury's death lay with senior managers at the Trust, which was criticised by a public inquiry for the "routine" neglect of patients between 2005 and 2009.
"This was a wholly avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it," he said.
He added: "As repeated investigations have revealed, there was a systemic failure at Stafford Hospital in relation to two of the most basic tenets of patient care: proper hand-overs between nursing shifts, and proper record-keeping.
"These failures put legions of patients at Stafford Hospital at serious risk. The simple fact is that Mrs Astbury died because she was not given the insulin that she needed."
The Trust is running an annual operating deficit of about £11m and became in April the first foundation trust to go into administration.'Candid' about failures
Commenting on the court case, deputy chief executive of Mid Staffordshire NHS Foundation Trust, Jeff Crawshaw, said the court case marked "the final stage in what has been a thorough and long-running investigation into the failings which led to her tragic death".
Mr Justice Haddon-Cave faced a tough choice when deciding how much to fine the trust.
He had to send out a clear message that failings of this kind are completely unacceptable, whilst acknowledging the Mid Staffordshire Trust is a very different organisation to the one that caused Mrs Astbury's death.
In the end it was the trust's early admission of guilt which saved it from a much larger fine.
Ultimately though it's not just the Trust which needs to learn the lessons of this heartbreaking episode but the whole of the NHS.
"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."
In assessing the size of the fine, the judge said the Trust had shown a high degree of co-operation with the authorities and had been "entirely candid" about its failures.
Mrs Astbury's friend and carer Ron Street said he was saddened that the health executives and line managers in charge at the time of her death would not be prosecuted.
He said: "After six-and-a-half…years in pursuit of justice for Gillian, during which I have too often found myself foolishly attempting to debate common sense with those being forced to defend the nonsensical, I have sufficient remaining sense to know that now is the time to say 'enough is enough'."
Peter Galsworthy, for the Health and Safety Executive, said: "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.
"We expect lessons to be learned across the NHS to prevent this happening again."
The HSE confirmed it was investigating two more deaths at the hospital - those of Ivy Bunn, who died in 2008, and Edith Bourne, who died in July 2013.
Following the ruling, assistant Chief Constable Nick Baker, from Staffordshire Police, said the force was continuing to work with other agencies, including the Crown Prosecution Service (CPS) to identify the most serious cases between 2005 and 2009 where alleged neglect at the hospital contributed to a patient's death.
To date, none of the cases have resulted in charges from the CPS.