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Mid Staffs faces prosecution over patient death


Mid Staffordshire Foundation Trust is to be prosecuted by the Health and Safety Executive, following the death of a patient in April 2007.

Gillian Astbury, who suffered with dementia, died after nurses failed to ensure she received vital daily injections of insulin. She slipped into a diabetic coma and died.

The HSE said the trust would be charged with breaching the Health and Safety at Work Act, but added that no individual nurses would face prosecution due to “insufficient evidence under health and safety laws.”

When Ms Astbury was admitted to the hospital, some nurses at the trust were not informed she had diabetes and others claimed they were too busy to check her notes.

Despite her high blood glucose levels, no action was taken by nursing staff. The jury at the inquest into her death concluded there was a “gross failure to provide basic care”.

Peter Galsworthy, head of operations for the HSE in the West Midlands, said: “We have concluded our investigation into the death of Gillian Astbury at Stafford Hospital and have decided there is sufficient evidence and it is in the public interest to bring criminal proceedings in this case.”

“Gillian Astbury died on 11 April 2007, of diabetic ketoacidosis, when she was an in-patient at the hospital. The immediate cause of death was the failure to administer insulin to a known diabetic patient.

“Our case alleges that the trust failed to devise, implement or properly manage structured and effective systems of communication for sharing patient information, including in relation to shift handovers and record-keeping,” he said.

However, the HSE said there was “insufficient evidence” to bring prosecutions against individual staff under health and safety laws.

The Crown Prosecution Service has previously ruled there was insufficient evidence to support manslaughter charges against any individuals.

Mid Staffordshire Foundation Trust is due to appear at Stafford Magistrates’ Court on 9 October.

During the Mid Staffordshire public inquiry the HSE admitted its practice was to ignore the law in relation to investigating deaths as a result of “clinical decisions about diagnosis or treatment”, due to a lack of resources.

It has since pointed out that it does investigate and prosecute some “exceptional cases” of this type.

In his public inquiry report Robert Francis QC described the situation as a “regulatory gap” and recommended the Care Quality Commission be given the power to prosecute trusts.

The government has said it will ensure sufficient resources are made available to the HSE.

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Readers' comments (24)

  • We need people prosecuted for this tragedy, not institutions.
    It ends up as a cost & liability on innocent taxpayers.
    Most of which would say that this was carried out 'Not in their name'

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  • I agree absolutely with Mr Smith. Things will never change as long as the Trusts are the ones taking the responsibility. When the laws of this country are changed so that individuals become accountable for their acts and omissions in care things will change but not before.

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  • ...I agree with John Smith, individuals must be held accountable, struck off, prosecuted and sent to prison. Until this happens nothing will change.

    The regulators are toothless and take far too long. My professional experience of safeguarding and the NMC is it takes over a year to take action on anything.

    We need to bring back the old ( and much better ) schools of nursing in the hospitals, have a legal minimum nurse to patient ratio which needs to be far higher, combined with constant robust supervision at all times.

    ...Will this happen ? Only if the public shout loud enough and threaten not to vote for the government. Its up to all of us to change can be done.

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  • Why are the nurses always the first to be blamed? How about investigating the doctor who admitted and clerked this lady and didn't prescribe the insulin?

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  • I agree with the above post and blame the Dr's for not prescribing the insulin in the first place and the system for bringing in that much paper work that the poor nurses didn't have time to go through her old notes.

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  • I would agree that both nurses and doctors are accountable. Yes the Dr shoulds have prescribed the insulin, but how could those nurses record high blood glucose and then not action them. That is the criminal element so yes those indiviudals should be prosecuted for willful neglect.

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  • re senior managers

    from the Committee of Standards in Public Life

    "The Seven principles of public life"

    "Standards matter
    A review of best practice in promoting good behaviour in public life"

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  • I agree with John Smith

    if the report is correct that no action was taken on elevated blood glucose levels it is a case gross professional negligence and total failure in duty of care of the patient by those directly involved and should be punished accordingly.

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  • Hello all,
    Some very interesting comments and debate. Please keep the discussion going. I just wanted to address one point raised by a few commentators who said the Dr involved did not prescribe insulin. Please see below an extract from the report by Robert Francis QC:

    "There is absolutely no doubt that the fact of her diabetes and the need for insulin was something known to some members of staff and recorded in Mrs Astbury’s records. They contain a note from Mr Street to that effect. The A&E records include a diabetes care plan including the need to give insulin, monitor blood sugar, and observe for hypoglycaemia.

    The admitting doctor in the ward to which she was initially sent made a note of the diabetes and ordered that if her blood sugar rose beyond a specified level at any of the four blood tests to be conducted daily, she was to receive Actrapid. A daily dose of insulin was also to be given. The doctor entered the prescription on a drug chart. A referral to a dietician was also required. Mrs Astbury developed suspected C. difficile and was transferred to Ward 8
    on 8 April. While there the nursing shift coming on duty failed to undertake appropriate observations or administer insulin when required."

    Thank you

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  • George Kuchanny

    Thanks for the clarification Shaun. It is also my opinion, in line with the other posts, that making institutions the target of blame is a waste of time and resource, most especially when we can see that we are dealing with a good well managed Trust.

    Individuals make healthcare work or fail in the end.

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