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Mid Staffordshire Foundation Trust

HSE launches criminal probe into Mid Staffs patient death


A criminal investigation has been launched by the Health and Safety Executive into the death of a woman at Stafford Hospital in 2007.

The HSE today announced it has started a formal investigation into the death of Gillian Astbury, who died after staff failed to give her vital insulin medication.

Mrs Astbury, who needed daily injections of insulin, slipped into a diabetic coma and died at the scandal-hit trust in April 2007.

The HSE had delayed holding an investigation until the conclusion of the public inquiry into failures at Mid Staffordshire Foundation Trust by Robert Francis QC.

A spokesman for the HSE said: “We can now confirm that our inspectors have today formally started an investigation.

“Our focus will be on establishing whether there is evidence of the employer or individuals failing to comply with their responsibilities under the Health and Safety at Work Act.”

The Crown Prosecution Service has previously ruled there was insufficient evidence to support manslaughter charges against any individuals in relation to the case, and it was passed to the HSE to consider if there had been breaches of health and safety legislation.

During the public inquiry the HSE admitted its practice was to ignore the law in investigating deaths as a result of healthcare failings, due to a lack of resources to do so.

The government said last month it would now make sure resources are available to the HSE as part of its response to the recommendations by Mr Francis.

Evidence about Ms Astbury’s death was heard by the public inquiry, which identified a failure by NHS West Midlands, and specifically its head of nursing Peter Blythin, to properly investigate what happened.

Despite details of the incident being emailed to Mr Blythin, now director of nursing at the NHS Trust Development Authority, the strategic health authority took no action between July 2007 until January 2010.

It only asked the Mid Staffordshire trust for details of what action had been taken in 2010, after an inquest concluded the failure by nursing staff to administer Ms Astbury with her insulin amounted to a “gross failure to provide basic care”.

Some nurses at the trust were not informed Ms Astbury was diabetic and others claimed they were too busy to check her notes.

Despite her high blood sugar levels no action was taken by nursing staff and the jury at the inquest into her death found failures in the “implementation, monitoring and management of the systems in place”.

They added: “Nursing facilities were poor, staff levels were too low, training was poor, and record-keeping and communications systems were poor and inadequately managed.”

Following the HSE announcement Julie Hendry, director of quality and patient experience at the Mid Staffordshire trust, apologised for the “appalling care Ms Astbury received”. She added: “A full investigation into her care and treatment was carried out.”

She said: “The recommendations from that investigation were implemented.  Actions included raising staff awareness about the care of diabetic patients and improving the information and system for nurse handovers.

“In 2010 we reviewed Ms Astbury’s dreadful care and as a result, disciplinary action was taken. 

“We will of course cooperate fully with the Health and Safety Executive’s investigation.”


Readers' comments (6)

  • Pardon me for being picky here, but, when I read, in the above report that, 'Some nurses at the trust were not informed Ms Astbury was diabetic and others claimed they were too busy to check her notes.,,', I am absolutely flabbergasted.
    What happened to so-called 'identified nurse' and care plans, and all that perlarva, may I ask?
    ALL nurses should make it their duty to know their patients medical reason for being in hospital. There is no excuse for 'ignorance or negligence, in the field of nursing.
    I realise I must be sounding OTT, But,
    What happened to the knowledge they learnt in their basic nurse training??? Oh, I forgot, they studied in universities/ colleges didn't they. Therefore, probably never had face to face contact with a real patient, until it was too damn late!!!!

    Nurses of my generation, would have been expected to receive and give a daily, detailed 'handover of care, from a qualified member of staff, to the 'on coming, ward staff. On most occasions where student nurses were working on the wards, they too were encouraged to do the 'handover to the next shift of staff. In my humble opinion, there is NO Excuse for a failure of duty of care to patients.

    Why can't the responsible people, i.e, trust managers, nurse Tutors, mentors, and all those who are supposed to be 'informed' on the education process, actually pass on their expertise to those staff in their employment and or, under their supervision?
    It reveals just how the NHS deteriorated over the decades. Poor old 'Florence' would turn over in her grave, if she were alive tiday!

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  • scott2121210

    In response to the post 13-Apr-2013 1:11 am I too am flabbergasted at this total breakdown of basic nursing care which unfortunately came at the cost of a human life!

    However, I must point out that as a 'University Educated Nurse' my nursing skills, knowledge, levels of observation, etc. are the pinnicle of my responsibilities as a professional Nurse where my sense of a duty of care towards any patient in my care will always be at the forefront of everything I do and honour as a Nurse.

    All I am trying to say is that you can't put that blanket statement on all Nurses who were educated at University level. I do agree though with everything else you have said.

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  • michael stone

    The point is, this is all TOO SLOW !

    It happened in 2007 - investigating something that happened in 2007, should not be done in 2013, because working out the exact details of what really happened, is then almost impossible !

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  • Part of the action plan should have been be to insist that every nurse undertakes a programme of education to note the signs of a deteriorating patient. Diabetic and asthmatic patients are unique in that they are not confined by age (are often young and relatively well and will not notice their own deterioration, but will have the potential to deteriorate very quickly to a life threating situation.
    All nurses and doctors need to be reminded of this - it is not just awareness - it needs education within the practice environment and professional leadership on each and every ward.
    Really good paper - associations of patient safety outcomes with models of nursing care organisation at unit level in hospitals- International Journal for Qaulity in Health Care 2013:vol 25, Number 2 pp 110-117

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  • Are we miising a point,I presume this lady wask seen by an admitting doctor. Did she just walking of the street or was she sent in by her GP if so she should have had at least a letter with her. The admitting doctor should then have recorded her diabetic medications including her insulin along with everything else on a kardex. So if this lady received other medications when in hoospital why not her insulin

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  • Kick the Donkey as usual , without a doubt Mid Staffs had major Management problems, as long as Nurses keep taking the blaim and protecting Managment nothing will improve.
    Stop covering up go to "Safeguarding" and/or the CQC like your collegues in the Private Sector, they have motivated and acheived massive improvements over the last ten years. instead of deriding them maybe you could learn from them. Most registered Managers of Nursing Homes are actually Nurses by the way

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