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Mid Staffs faces prosecution over patient death

Mid Staffordshire Foundation Trust is to be prosecuted by the Health and Safety Executive, following the death of a patient in April 2007.

Gillian Astbury, who suffered with dementia, died after nurses failed to ensure she received vital daily injections of insulin. She slipped into a diabetic coma and died.

The HSE said the trust would be charged with breaching the Health and Safety at Work Act, but added that no individual nurses would face prosecution due to “insufficient evidence under health and safety laws.”

When Ms Astbury was admitted to the hospital, some nurses at the trust were not informed she had diabetes and others claimed they were too busy to check her notes.

Despite her high blood glucose levels, no action was taken by nursing staff. The jury at the inquest into her death concluded there was a “gross failure to provide basic care”.

Peter Galsworthy, head of operations for the HSE in the West Midlands, said: “We have concluded our investigation into the death of Gillian Astbury at Stafford Hospital and have decided there is sufficient evidence and it is in the public interest to bring criminal proceedings in this case.”

“Gillian Astbury died on 11 April 2007, of diabetic ketoacidosis, when she was an in-patient at the hospital. The immediate cause of death was the failure to administer insulin to a known diabetic patient.

“Our case alleges that the trust failed to devise, implement or properly manage structured and effective systems of communication for sharing patient information, including in relation to shift handovers and record-keeping,” he said.

However, the HSE said there was “insufficient evidence” to bring prosecutions against individual staff under health and safety laws.

The Crown Prosecution Service has previously ruled there was insufficient evidence to support manslaughter charges against any individuals.

Mid Staffordshire Foundation Trust is due to appear at Stafford Magistrates’ Court on 9 October.

During the Mid Staffordshire public inquiry the HSE admitted its practice was to ignore the law in relation to investigating deaths as a result of “clinical decisions about diagnosis or treatment”, due to a lack of resources.

It has since pointed out that it does investigate and prosecute some “exceptional cases” of this type.

In his public inquiry report Robert Francis QC described the situation as a “regulatory gap” and recommended the Care Quality Commission be given the power to prosecute trusts.

The government has said it will ensure sufficient resources are made available to the HSE.

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Readers' comments (24)

  • We need people prosecuted for this tragedy, not institutions.
    It ends up as a cost & liability on innocent taxpayers.
    Most of which would say that this was carried out 'Not in their name'

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  • I agree absolutely with Mr Smith. Things will never change as long as the Trusts are the ones taking the responsibility. When the laws of this country are changed so that individuals become accountable for their acts and omissions in care things will change but not before.

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  • ...I agree with John Smith, individuals must be held accountable, struck off, prosecuted and sent to prison. Until this happens nothing will change.

    The regulators are toothless and take far too long. My professional experience of safeguarding and the NMC is it takes over a year to take action on anything.

    We need to bring back the old ( and much better ) schools of nursing in the hospitals, have a legal minimum nurse to patient ratio which needs to be far higher, combined with constant robust supervision at all times.

    ...Will this happen ? Only if the public shout loud enough and threaten not to vote for the government. Its up to all of us to change things....it can be done.

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  • Why are the nurses always the first to be blamed? How about investigating the doctor who admitted and clerked this lady and didn't prescribe the insulin?

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  • I agree with the above post and blame the Dr's for not prescribing the insulin in the first place and the system for bringing in that much paper work that the poor nurses didn't have time to go through her old notes.

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  • I would agree that both nurses and doctors are accountable. Yes the Dr shoulds have prescribed the insulin, but how could those nurses record high blood glucose and then not action them. That is the criminal element so yes those indiviudals should be prosecuted for willful neglect.

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  • re senior managers

    from the Committee of Standards in Public Life

    "The Seven principles of public life"

    http://www.public-standards.gov.uk/about-us/what-we-do/the-seven-principles/

    "Standards matter
    A review of best practice in promoting good behaviour in public life"

    http://www.public-standards.gov.uk/wp-content/uploads/2013/01/Standards_Matter.pdf





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  • I agree with John Smith

    if the report is correct that no action was taken on elevated blood glucose levels it is a case gross professional negligence and total failure in duty of care of the patient by those directly involved and should be punished accordingly.

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  • Hello all,
    Some very interesting comments and debate. Please keep the discussion going. I just wanted to address one point raised by a few commentators who said the Dr involved did not prescribe insulin. Please see below an extract from the report by Robert Francis QC:

    "There is absolutely no doubt that the fact of her diabetes and the need for insulin was something known to some members of staff and recorded in Mrs Astbury’s records. They contain a note from Mr Street to that effect. The A&E records include a diabetes care plan including the need to give insulin, monitor blood sugar, and observe for hypoglycaemia.

    The admitting doctor in the ward to which she was initially sent made a note of the diabetes and ordered that if her blood sugar rose beyond a specified level at any of the four blood tests to be conducted daily, she was to receive Actrapid. A daily dose of insulin was also to be given. The doctor entered the prescription on a drug chart. A referral to a dietician was also required. Mrs Astbury developed suspected C. difficile and was transferred to Ward 8
    on 8 April. While there the nursing shift coming on duty failed to undertake appropriate observations or administer insulin when required."

    Thank you

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  • George Kuchanny

    Thanks for the clarification Shaun. It is also my opinion, in line with the other posts, that making institutions the target of blame is a waste of time and resource, most especially when we can see that we are dealing with a good well managed Trust.

    Individuals make healthcare work or fail in the end.

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  • It is sad to read such stories of failings in a cash strapped NHS where pressure of work forces health professionals to constantly complete "Tick Box" exercises due to the need to cover your backs from legal beagles, national watch dogs and the pack of wolves waiting to seize on any opportunity they can.
    There but the grace of god go a few NHS hospitals, one step away from a mistake which will be pounced upon by the media.
    No, I am not in the debate on the arguments for or against, but listen with intent. I then say "What action do we ALL need to do to stop this happening again."
    What I see is a lot of talk, from professionals, colleagues and peers, but no action.
    What I also see are patients sitting, laying in a bed that could take more of a proactive approach in helping to monitor the NHS in real time. A list of my patients daily requirements (Meds, Fluids, Food, Toilet, cleanliness) which is filled in each day by me the patient or their carer.
    No it won't stop mistakes, but will give a small voice to the patient to say "Hey the NHS Service was good, but I didn't get my meds on time 3 of the 4 days..."
    If any Trust would like to pilot this concept feel free to steal the idea, but please let me know.
    Patients could do so much more for you, if you would only ask us how!

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  • tinkerbell

    Was this because they were never handed over the information? I am stunned on occasions at the ineffective communication amongst staff. Once a piece of vital information is not handed over correctly with continuity it can become easily lost.

    Effective handovers are paramount to ensuring that every member of the team are in the 'know' when they take over the shift.

    We always had a set format for our handovers so that even an unfamiliar agency nurse would have vital information, supplemented by a handover sheet for further reference from the previous shift.

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  • It sounds like a series of very unfortunate incidents. E.g. The lady had dementia therefore was unable to tell staff she needed her insulin. I imagine no insulin pens were supplied with her on admission which is very unusual for a patient with unstable diabetes. Also no relatives checked if she was receiving her insulin, must have assumed staff knew. Why was the insulin which was prescribed overlooked? Was it only prescribed on the white sheet which might have been hidden in the paper work and not on her actual drug chart I wonder? What ever happened it is a lesson to us all and very frightening to think that such a tragedy could happen

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  • Lets hope that the HSE drags the real villains into court as the evidence provided could prove to be illuminating !

    The massive cuts in the numbers of nurses at Mid Staffs during these peoples tenure need explaining !

    We need to hear from Nicholson, Bower, Brisby, Yeats and "nurse" Jan Harry.

    They all should be summoned to give evidence, under oath and be subjected to rigorous cross-examination.

    Its all to easy for unsupported nurses on poorly staffed wards to be blamed for a situation deliberately created by senior "managers"

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  • i feel nurses are under so much pressure that they need extra support like 2 nurses and a hca working in areas, this way, one nurse will be helping the hca with personal care of a patient while the other nurse can concentrate on the drug rounds and make a jobs list for the doctors. this is expensive at the start but i'm sure it would be beneficial in the long run.

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  • An employer IS legally liable for the actions of it's employees providing the employees follow the procedures put in place by the employer, this is vicarious liability. In this case, if I have read it right, there were insufficient procedures in place, which is why the trust as an employer are being prosecuted. As employees can only be prosecuted as individuals if they do not follow the employers guidelines under the Health and Safety at work act, no prosecution can be brought by the HSE if adequate guidelines do not exist as there is nothing to measure the employees actions against. This only applies to H&SAW. Individuals could be held responsible under other legislation, for example offences against the person act. They could also be sued for negligence.

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  • George Kuchanny

    tinkerbell | 29-Aug-2013 7:49 pm
    and
    Jenny Jones | 30-Aug-2013 5:42 am

    Agreed.

    Mid Staffs I think is responsible for Stafford Hospital. Correct me if I am wrong please. This hospital has a disgraceful track record. So bad that we can be fairly sure that things were wrong for a long time and that it was wrong from top to bottom.

    Chapter and verse has already been aired in the papers at great length.

    The most infuriating thing about the whole debacle is that it had nothing much to do with the usual lack of resources often found at the root of other failings. It was due to a culture of complete indifference to the state patients were getting into.

    No help, no compassion. Nothing. Just treated as nuisances to be ignored and even occasionally abused. If we believe only a part of what we have seen in the newspapers.

    I have a friend in Dallas TX who emailed me expressing deep concern about the whole mess. How embarrassing is that?

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  • George Kuchanny 30-Aug -2013

    Stafford Hospital had terribly low Nursing staff levels at the time of all these tragedies. It was known by the Director of Nursing at the hospital and the Chief Exec that staffing levels were dangerously low, they deliberately kept this information from the Board as they were intent on pursuing foundation status. Yes there was a lack of compassion, stemming right from the very top of the organisation. I believe a culture in any company or organisation is created at the top and filters down.

    If individuals are to be prosecuted lets start with those who were in charge of this hospital and took all the crucial decisions regarding safety and staffing.

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  • It is true that there is a case for individual prosecutions but it is still the employer who is to blame for appointing managers who do not ensure good nursing practice. I am personally aware that at times you can raise issues relating to poor practice which are often not dealt with sufficiently. You need to be a strong individual to continue to raise those issues when you are in turn intimidated. I will continue to follow the guidelines by the NMC and keep raising concerns when necessary.

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  • George Kuchanny

    Sarah Brooklyn | 30-Aug-2013 10:38 am
    and
    Anonymous | 30-Aug-2013 1:21 pm

    Thanks, you make valid points.

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