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.