Nursing failures led to Staffordshire death

9 September, 2010

A systematic failing to provide adequate nursing facilities, combined with low staffing levels, contributed to the death of a 66-year-old diabetic at a Staffordshire hospital, an inquest jury has ruled.

Gillian Astbury slipped into a fatal diabetic coma at scandal-hit Stafford Hospital in 2007.

Jurors concluded that the failure to administer insulin to the patient amounted to a gross failure to provide basic care.

Following a two-day inquest, the 10 members of the jury said Mrs Astbury’s death was contributed to by a failure to record glucose levels and by staff not communicating or reading clinical notes properly.

In its verdict, the jury said: “Nursing facilities were poor, staff levels were too low, training was poor and record-keeping and communications systems were poor and inadequately managed.”

The inquest heard how Mrs Astbury, from Hednesford, died early on 11 April 2007, while being treated for fractures to her arm and pelvis.

The jury, sitting at Stafford’s County Buildings, heard that the pensioner’s blood sugar levels were not properly monitored and insulin was not administered on the day before her death, despite being prescribed by doctors.

The court heard that some of the nursing staff were not informed that Mrs Astbury was diabetic and some said they were too busy to check the patient notes at the foot of her bed.

Antony Sumara, chief executive of the hospital, has apologised for Mrs Astbury’s care and the local NHS trust has admitted full liability in separate civil proceedings.

Readers' comments (16)

Anonymous | 9-Sep-2010 1:54 pm
In the current climate of forced savings in the NHS and streamling roles then sadly we may see more of this type of tragic incidents in the near future.
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Anonymous | 9-Sep-2010 3:24 pm
I agree. I think the health authorities need to take a certain amount of responsibility for this. All too often they employ staff with little or no experience, or simply not enough staff to try to save money and cut corners. It does not work. It is time for the nhs to wake up and smell the coffee.
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mike | 9-Sep-2010 7:01 pm
I think this is another case of Nurses being blamed for failures of working conditions that are imposed upon them.

It is about time management and policy (or lack of it in the form of a Nurse patient ratio for example) shoulders the blame.
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K W | 10-Sep-2010 9:48 am
Mike, absolutely spot on. Nurses are a very easy scape goat for errors where in fact they are put in situations where they are almost set up to fail. I have sat in various management meetings and that attitude is obvious there - there's the non-clinical managers who put all this extra work on the floor staff and their attitude is 'well we all need to try harder'. But of course when the proverbial hits the fan, the managers sit in their little bubbles being safe from the backlash that the poor nurse who simply hadn't got the time to do what she needed to do because of all the other stuff she had to do too.
I would bet my entire retirement pension fund that this situation is not unique. I bet there is a similar situation day in day out at every trust, just most of them don't get to this stage. I reckon that if a situation ever occured where the managers would be the ones accountable and responsible for these situations and blame taken off the nurses then the staffing/workload/pressure problems would miraculously go away very quickly. But until that time, all us nurses better watch our backs - there's always someone right behind you with something to stick in it...
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Anonymous | 10-Sep-2010 10:58 am
i totally agree with the comments above. on a fully staffed morning 6 -7 memmbers of staff are expected to be on duty on my ward but almost half the time its only 4. how do u justify this and expect the quality of care to be of same standard. at the same time we are are talking about elderly patients with some needing a lot of assistance with personal cares or totally dependent. this is not to say lack of glucose monitoring or insulin administration is justifiable. however i am never a fan of nurses who always say i wasnt infrmed or it wasnt handed over. i would however be interested in knowing how many insulin doses were omitted & also how often the BGMs were monitored because even if this was missed a few times someone would most likely have picked the problem before it got out of hand.

i really feel for nurses because at times you have to constantly keep thinking if you have missed something even after work due to lack of staffing levels.
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oohMatron | 10-Sep-2010 12:52 pm
...don't forget that when Mrs. Astbury died, the Trust were in hot pursuit of Foundation status and all that accompanies that particular folly. This of course meant that costs were consistently being driven down and no budgets were exempt - and of course the nursing budget was a major target.
My understanding is that the Trust is now in much more capable hands and the standards of care have improved as establishment levels have been allowed to increase. However, we must never forget the appalling standards that were allowed to develop that contributed to this poor lady's death - and learn the lessons of what can happen when Trust management teams ignore the warning bells in pursuit of financial 'balance'.
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mike | 10-Sep-2010 2:13 pm
Keith, you've hit the nail on the head mate! It should be the managers and non clinical managers in particular who are held to account over failings and decisions (especially staffing levels and cost cutting), and I mean to the same level we are. If just ONE non clinical manager went to jail for negligence that contributed to a death of a patient, how soon do you think a lot of these problems would go away as they all run round like headless chickens trying to protect themselves?
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Heidi McNair | 11-Sep-2010 9:58 am
I agree with the first comment. The cuts keep coming and the patient is lost somewhere under mounting paperwork, legislation, oh, and then the nurse is there somewhere!
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P. Damien | 14-Sep-2010 1:19 pm
Who is responsible for poor staffing levels?

Ward manager?

Middle management?

Chief nurse for the trust?

Executive board?

Government?

Unions?

One could argue all are to blame. Until nurse/patient ratios are determined by law this will continue to happen. And we all know it will continue to happen because ultimately the government doesn;'t want nurse/patient ratios as it would be too 'expensive'. Could a charge of corporate man slaughter be levelled against the trust in question. Are the govt breaching an article of the Human rights charter? Probably. Was the death in question unlawfull?

Human life in the UK does have a price and it is one our politicians aren't prepared to pay.
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bob | 14-Sep-2010 3:01 pm
Here here P Damien!
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Anonymous | 14-Sep-2010 3:39 pm
Did the nurses put incident forms in when they were short staffed? If they did and they informed their managers and still nothing was done, then it would be the managers fault. If they didn't then it was their fault. Did they prioritize their work properly? If non-urgent washes, bed making etc was done and insulin administration wasn't, then it was the nurses fault. It's not rocket science.
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Steve Williams | 14-Sep-2010 5:01 pm
Dear old Nursing Times, exactly whose side are you on? Certainly not the nurses' judging by the bias in your reporting. Why title this article “Nursing failures led to Staffordshire death” why not say “Low staffing levels contributed to Staffordshire death” instead?

God forbid that you should be seen to support the very people that buy the NT in the first place. Don't you even read some of the many replies you get on this forum crying out about low morale caused by even lower staffing?

In fact if you want to appear journalistic and objective why not use the headline “Nursing failures and inadequate staffing levels led to Staffordshire death” instead?

P Damien came up with a very interesting list of people who might be responsible for poor staffing levels through their inaction and studious silence. Ward managers, Middle management, Chief nurse for the trust, Executive board, Government, Unions?

A very good list but I'd suggest there's one candidate missing... a certain national magazine for nurses that is supposed to report stories objectively and try to spread the message to whoever will listen that staffing levels are dropping to a lethal low and it's NOT the fault of the front-line nurses!
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carolyn deegan | 15-Sep-2010 8:36 am
What ever happened to a medical ward round? As an inpatient she should have been assessed so what happened to the doctors?Yes I agree not always the nurses fault but if an experienced nurse on duty then she/he has a duty to care and we cant always blame paperwork. she was on the ward too many days for staff to not be aware she was a diabetic!
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dino-nurse | 16-Sep-2010 1:57 pm
Staffing levels on general/acute wards will continue to be too low until a law is passed forcing Trusts to have a minimum RN to patient ratio. At the moment Trusts use the useless nurse/bed occupation ratio that allows anyone with a PIN to be called a nurse, regardless of whether they have direct patient contact or not. Brilliant idea eh? How many clinical managers do you know who could manage an arrest on an acute admissions unit? Or spot a septic patient? Its about time that ANYONE with a PIN should have to do a set number of clinical days per year in an acute setting, in order to keep up-to-date. This would include university nurse lecturers by the way...come see how your students are actually being taught out here. It might also point out to the other dinosaurs that trained with me that todays nurses are dealing with far more complex cases. Many of the patients currently nursed on acute medical wards would have been in the ICU 20 years ago. Not that any of this will happen though. All CEOs want to do is stay under budget- they do not give a monkeys about patient care.
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Steve Williams | 16-Sep-2010 2:42 pm
Okay carolyn deegan - I am being serious now.

Without a full transcript of the inquest jury's findings I can't honestly say why this fatality occurred. The Nursing Times article provides insufficient detail to summarize even a working theory.

NT, like the Daily Mail, is about sensationalism and selling copy – not concise and accurate journalism or reporting.

I am totally baffled by the lack of detailed information that such a (supposedly) august publication as the NT has been unable to impart to its fellow professionals in the NHS. Perhaps the NT just gets its stories from the newswire and then re-cycles them with little, or no, effort to actually go out and do some investigative journalism of their own!

OK UK – rant mode is over!

It has been ten years since I practised as an RN in the UK. BUT - It seems incongruous to me that UK standards would have slipped so far behind those of Canada, where I now work.

Something is missing in this picture/report - and not just the insulin injections!

I'd like to see the full details before I made a subjective observation on this case.

However...

In the meantime I can tell you how we do this stuff in Canada and how it would be less likely to happen here.

No, I am not being arrogant or facetious. I am merely describing to you how our policies and procedures work on this side of the pond...

If someone comes into our facility – the physician sees them and then writes down his orders using a Medi-Pen - and special paper - which are relayed to the pharmacy once the pen is docked in the pen holder.

The on-duty RN transcribes those orders onto the MARs using the same pen and then signs the original order as having been duly copied. The orders then have to be signed by a second Registered Nurse – using the Medi-Pen – to verify authenticity. Three checks.

If we have no stock meds in our “Emergency Box” and our Toronto pharmacists cannot supply us, then we are given licence to source from 'local' sources like “DrugMart.”

Having transcribed all this to the MARs and TARs – by RNs - it escapes me how a diabetic could have fallen through the net?

The RPNs who administer the medications have a duty to follow the current MARs sheet. Hey! Am I talking Spanglish here?

Okay. I am well out of date now... But doesn't the NHS have a similar system?

Yeah, just maybe, this was an accident waiting to happen!

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Steve Williams | 16-Sep-2010 2:53 pm
Whoops!

I forgot to quote my sources!

The MediPen – Pen2Net is at

http://www.compupen.com/Healthcare_Pens/healthcare_pens.html

Read it and weep.

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