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Mid Staffs nurse struck off after patient death

A former nurse at Mid Staffordshire Foundation Trust has been struck off by the Nursing and Midwifery Council after she failed to ensure a diabetic patient received vital insulin medication.

Senior staff nurse Ann King was struck off the register by an NMC fitness to practise panel on Friday while ward manager Jeannette Coulson was handed a three year caution order. Both were found guilty of errors that contributed to the death of 66-year-old Gillian Astbury in April 2007.

Ms Astbury was admitted to Stafford Hospital after a fall which fractured her pelvis. Despite her need for insulin being documented and prescribed, both nurses did not check her notes or ensure observations were taken and that the insulin was given. Ms Astbury went for 48 hours without insulin and ultimately slipped into a coma and died.

The NMC panel found the fitness to practise of both was impaired and their behaviour amounted to misconduct.

Ms Coulson and Ms King, who have both now retired from nursing, were also found guilty of a series of failures between 2005 and 2010, including swearing at patients and lying about putting fresh dressings on wounds.

In a letter to the NMC, Ms King blamed “systemic issues including poor staffing levels” at the trust, along with a poor ward layout and the failure of management to listen to staff concerns.

She said she and her colleagues “did their best under difficult conditions where staff who left were not replaced and the trust was concerned only with balancing the books”.

She accepted mistakes had been made in the care of Ms Astbury and claimed better staffing levels would have given her time to read Ms Astbury’s notes.

But the panel found Ms Astbury died “following a lack of care”. It said: “The panel is concerned that Mrs King, whilst admitting mistakes and expressing remorse, appeared keen to shift responsibility to others. The panel is clear that, during her shift, she was the nurse in charge of the team, with responsibility for [Ms Astbury].”

The panel accepted there were wider problems at the trust and that Ms King was not “solely responsible”, but added: “The failings of others cannot detract from the personal responsibility and accountability of Ms King for her own practice.”

Confirming the striking off order the panel said it was “the only sanction sufficient to protect the public and to maintain proper standards of conduct so as to maintain trust and confidence in the profession and in the NMC as a regulator.”

In relation to Ms Coulson, the panel said “the failings of others were of greater significance in contributing to [Ms Astbury’s] death than those of Ms Coulson.”

It concluded striking her off the nursing register would be “disproportionate” and instead chose a three year suspension.

This it said would “meet the public interest in conveying a message to the public and the profession about the importance of effective management and leadership in promoting and sustaining good clinical practice”.

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Readers' comments (17)

  • To have a patient die like this is unforgivable but surely other nurses and doctors were involved in Ms Astbury's care during that period.

    Is this a case of using them as scapegoats for the whole Mid Staffs episode, publicise their punishment and all will be well again.

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  • It does seem a bit suspect that only two people have been dealt with when many others must have been involved. However other professional failings are superficially mentioned in the report, so it is possible that others are either in the pipeline or they are dealing with multiple offenders first.

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  • Take note !

    Any registered nurse working in an understaffed and badly managed environment is clearly at risk of being scapegoated ! -

    We do not know all the details of theses cases but for sure we know Martin Yeats is enjoying a well funded NHS pension + the payoff received for failure !

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  • I find it disheartening that when these two Nurses mentioned the mitigating circumstances of staffing levels the NMC chose to interpret this as them trying to "shift the blame".

    Don't get me wrong if these two qualified nurses ignore this patients needs then they should be deeply ashamed, and punished. But we know there were serious issues at Stafford stemming from the very top of the organisation but it's seems to be the Nurses who are carrying the can.

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  • "Ms Coulson and Ms King, who have both now retired from nursing,"

    Er...
    What's the point of striking them if they are no longer nurses?
    And.....
    Didn't Mid Staffs happen last year? Why does the NMC take so long to get anything done?
    And.....
    I do feel the NMC should try and deal with all circumstances concerning the care given to the patient and know everything that was happening in the ward and the hospital at that time.

    What the nurses did was yucky but were they pushed into doing this? I am not a nurse and I do not work in the NHS so I may be saying something really silly next...
    What I mean is...
    We don't know how much pressure these nurses were under at the time. Its easy to condemn them now at our desks and our laptops...

    But if you were them, on this ward, would you have done the same thing?
    That's what's really frightening.

    Hospitals situation can change very quickly if new patients are coming in, and you know you have to check the patients notes but you really must do your rounds and check on this patient who is going home today and make sure she has all her painkillers and medicine. Then you have to deal with a handover and quickly get this new patient a bed and make sure its clean and comfortable....


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  • This is truly frightening for all nurses as we all know how bad staffing levels are in NHS hospitals. Too many managers on high salaries who do not listen when staff raise concerns as they are more interested in cutting budgets which generally means staff not being replaced when they leave and recruitment being frozen. I am aware of the need to save money but not at the cost of lives.

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  • she didn't have insulin for 48hrs - were these the only two nurses looking after her in a 48hr period?

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  • ...."you are personally accountable for actions and omissions in your practice..."
    Not having insulin for 48 hours and dying as a consequence is a really serious omission, don't you think?

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  • PDave Angel | 21-Sep-2013 1:36 pm

    Hole in one! You might not be a nurse but you see the whole situation really clearly. I wish the NMC paid more attention to these details but they are in such a mess they can't think straight any more.

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  • Anonymous 22 sept 3.17pm, I completely agree.

    The rest of you seem to think its ok to omit to such a severe degree that a patient dies just because the ward is busy or understaffed?? The whole of the NHS is busy and understaffed! I truly hope I NEVER end up in your care!

    It clearly says the medication was prescribed, why then, when the meds were being done did the insulin get missed for 48hours.

    The NMC is there to protect the patient, and under no circumstances is "the ward was busy" an excuse for such a disgraceful, repeated omissison that caused a woman to die.

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  • If we didn't tolerate understaffing, and we shouldn't, then many things would not go wrong. We have got to stop blaming everyone else. We know what happens to patient care when staffing, amongst other things, is inadequate. So why do we not refuse to work in such conditions? Why do we not lobby our unions for action and vote in their ballots? The victim mentality is putting patients at risk. It needs to stop.

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  • Anonymous | 22-Sep-2013 3:17 pm
    and Bernadette Johnson,

    Yes its appalling a woman died but would you have done exactly the same thing as those two nurses given the same ward circumstances they faced? That's what's truly frightening.

    We need to know what actually happened on the ward minute by minute before we can judge these two nurses. The NMC is only concentrating on the Nurses, not on the ward as a whole. Their actions are interconnected with everything that happened on that ward on those two days.

    The nurses mention understaffing. How much understaffing? How many patients were there? How many emergencies did they face? Were they rushed of their feet every few minutes?

    How many nurses were on that ward and how many should there have been and what were they all doing?

    Do doctors read the patient's notes as well?
    "Ms Astbury was admitted to Stafford Hospital after a fall which fractured her pelvis" Would a doctor have been involved and read the notes as well as the nurses?


    Am I being silly?
    Please tell me

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  • latasha-leanne

    It is a disgrace that a woman had to die in a place where she should've felt safe and looked after, and there's no excuse for it.

    I've read about this article on BBC News, with further reading of related news with regards to Stafford hospital. The first thing to catch my attention was this headline..
    "No action over Stafford Hospital Doctors"

    Now, tell me if I'm wrong, but last time I checked, working as a nurse also meant working effectively within a "multidisciplinary" team.

    Doesn't this surely mean that everyone of those staff attending to the woman's care, are somewhat responsible in their own way, regardless of their title, whether that be nurse, doctor, HCA, etc? Because something obviously failed somewhere within that team.

    latasha-leanne

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  • It is the responsibility of the SHO/Reg to provide a plan,write a drug chart and prescribe insulin for patients when needed not the nurse. Sounds as if these nurses have been used as scapegoats.

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  • Another example of nurse blaming. It is absolutely shocking that a patient died from lack of medication. However, as pointed out many times above; Where was the pharmacist checking patient prescription? ,where was the doctor who prescribed? where was the Consultant in charge of this lady's care? If the nurses are to blame -so is everyone else .
    Do we hear the NMC standing up for the patient by calling for action where are others are also at fault-no, of course not.

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  • Agreed, easy at desk/laptop to judge without full details of circumstances of those 48 hrs. YES, it is shocking and tragic that this happened and I would not have liked to explain to Ms Astbury's family & friends. But, the fact is that when wards are understaffed and stressed and pressurised, not to mention low morale, break down in teamwork and tired...for mistakes will happen. judge away, but this has been the dangerous situation on too many wards for too long.

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  • it is always the nurses that get the blame, why were they on duty for 48 hours non stop?i presume they must have been because no one else was called to acount

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