Hospital death: £200,000 fine
Health and Safety Executive v Mid Staffordshire NHS Foundation Trust (2014) Stafford Crown Court, April 28
Mid Staffordshire NHS Foundation Trust has been fined following the death of a patient.
Significant points of the case
Gillian Astbury, a 66 year old Type 1 diabetic, died from diabetic ketoacidosis at Stafford Hospital in April 2011 because of failures to implement basic handover procedures and to ensure essential record keeping.
Staff at the hospital did not follow or even sometimes look at medical notes which stated that Ms Astbury needed insulin, regular blood tests and a special diet.
The system for communicating patient needs at staff handovers was inconsistent. Record keeping and monitoring of patient care plans were far below acceptable standards.
Mistakes were made at up to eight shift changes and 11 drugs rounds. The failure to administer insulin was the direct cause of Ms Astbury’s death.
The HSE investigated the death in accordance with its policy to investigate health sector deaths where there was evidence that standards had not been met because of a systematic failure in management systems.
The Foundation Trust was fined £200,000 plus £27,000 costs for a breach of section 3, HSW Act, for failing to ensure the health and safety of non-employees.
Mid Staffordshire NHS Foundation Trust has been the subject of two major inquiries into events at Stafford Hospital between 2005 and 2009.