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Nursing failures led to Staffordshire death


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)

  • 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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  • 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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  • 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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  • 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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  • 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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  • ...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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  • 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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  • 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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  • Who is responsible for poor staffing levels?

    Ward manager?

    Middle management?

    Chief nurse for the trust?

    Executive board?



    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 cat

    Here here P Damien!

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