A nursing director was last week recalled to the Mid Staffordshire Foundation Trust public inquiry after unwittingly giving false evidence.
During his first appearance at the inquiry two weeks ago, Peter Blythin, director of nursing and workforce at NHS West Midlands, said he had not been made aware of a serious untoward incident (SUI) relating to the death of a diabetic patient at Stafford Hospital in April 2007.
Gillian Astbury was admitted following a fall and contracted C difficile but slipped into a fatal diabetic coma after she was not given her insulin. An SUI was lodged and an inquest ruled there had been a gross failure to provide basic care.
Mr Blythin was called back to the inquiry last week after it was discovered he had received an email in May 2007 about the circumstances surrounding Ms Astbury’s death – although Mr Blythin maintained he had not opened the document attached to the email which contained the detail.
Inquiry counsel Tom Kark QC told Peter Blythin he “was not suggesting for a moment you came along and deliberately told untruths”.
Mr Blythin, a former A&E nurse who registered in 1976, was questioned on why the Astbury case was closed in March 2010 when the strategic health authority still had not received an action plan from the trust stating how it planned to reduce the risk of a similar incident happening again.
SHAs are supposed to ensure that action plans relating to serious untoward incidents are put into practice.
The action plan was finally requested by the SHA in September 2010, more than three years after Ms Astbury’s death.
Inquiry chair Sir Robert Francis suggested the belated request was prompted by a letter from the coroner following the inquest’s verdict at the start of the month.
Mr Blythin accepted this was “in part” the reason, and said the case had been closed “because there was assurance given that the action plan and the root-cause analysis was in place”.
Mr Kark said it seemed the “purpose of sending SUIs to the SHA was, frankly, lost” in this case.