A £200,000 fine has been handed out to Mid Staffordshire NHS Foundation Trust after a series of failings led to the needless death of a diabetic patient at Stafford Hospital.
Gillian Astbury’s death in April 2007 was “wholly avoidable and tragic”, Justice Haddon-Cave told Stafford Crown Court this afternoon as he handed down the sentence.
He said that if the trust had been a profitable commercial organisation he would have imposed a fine in the region of £1 million. But he added: “The trust is, however a public body; it is in serious financial difficulty.”
Ms Astbury, a 66-year-old grandmother from Hednesford, was admitted to Stafford Hospital’s A&E on April 1 2007 after suffering fractures to her arm and pelvis in a fall at home.
Her friend and carer Ronald Street made it clear her “brittle” diabetes required regular monitoring, the court heard. She also needed daily insulin to control her condition.
But following poor standards in record keeping and lack of proper handovers between nursing shifts – described by the judge as “systemic failure in relation to two of the most basic tenets of patient care”, Ms Astbury was found collapsed on the evening of April 10. She died in the early hours of April 11 2007 from insulin deficiency.
The beleaguered trust, due to be dissolved later this year, admitted responsibility for Ms Astbury’s death and pleaded guilty to breaching the Health and Safety at Work Act at the first opportunity.
Justice Haddon-Cave described Ms Asbury as “a vulnerable patient who was admitted to hospital for care, but who died because of the lack of it”
“This fatality was not simply due to error and omissions by an individual nurse or nurses. The underlying causes were far more fundamental,” he said.
“Failures of organisation and management meant that nursing and medical staff were working within a lax and poorly-run system from the start.
“In my judgement, a significant fine is called for to reflect the gravity of the offence, the loss of a life and in order to send out a strong message to all organisations, public or private, responsible for the care and welfare of members of the public.
“The proper starting level of fine for the trust in this case would be £400,000. There must be a substantial reduction, however, for the early plea of guilty, for the early admission of responsibility and for the unprecedented level of co-operation by the trust with the various inquiries.
“The reduction should be greater than the normal. In my judgement, a reduction of 50 per cent is called for; accordingly the net fine which I impose is £200,000.
“If the fine has ultimately to be paid for by the Department of Health itself, then so be it. That is a matter for the authorities.
“It must be remembered that this case is the death of a much-loved person, Gillian Asbury. I wish to add my condolences to her family and friends to those that have already been expressed. No financial penalty can adequately equilibrate loss of life.”
Mid Staffordshire NHS Foundation Trust was also ordered to pay £27,094 in costs, requested by the Health and Safety Executive which brought the prosecution.
Speaking after the sentencing Peter Galsworthy, head of operations for Midlands HSE, said: “Gillian Astbury’s death was preventable. She just needed to be given insulin.
Gillian Asbury and her loved ones were failed by Mid Staffordshire NHS Foundation Trust. Every hospital patient has the right to expect more.”