Basic failures led to Mid Staffs 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 fined £200,000 and ordered to pay £27,049 costs.

Peter Galsworthy, HSE Head of Operations in the West Midlands, said: “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.”