May 2014 Legal Update:
Stafford Hospital fined £200,000 over patient death
Health and Safety in the NHS is very close the our hearts at Wallett HSE Services, we are involved in advising some NHS institutions. Some close family members have been directly affected by the poor health care which took place in Mid Staffs, which ultimately resulted in the various investigations and enquiries.
Mid Staffordshire NHS Foundation Trust admitted breaching health and safety law which saw the 66-year-old fall into a coma and die after nurses failed to administer crucial insulin injections.
At Stafford Crown Court today High Court judge Mr Justice Haddon-Cave said the case was "a wholey avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it."
Stafford Crown Court heard her death came as a consequence of bosses having 'no control' over the hospital.
Mrs Astbury from Hednesford was first admitted into Stafford Hospital on April 1, 2007 after breaking her arm and pelvis after suffering falls at Cannock Hospital and at home.
She died in the early hours of April 11 after lapsing into a fatal diabetic coma because two nurses failed to give her the required insulin injections.
But Stafford Crown Court heard it was not a one-off oversight that led to her death but a series of repeated failures to share information, hold proper staff hand-overs and keep records over eight nurse shifts and up to 11 drug rounds.
Prosecutor Mr Bernard Thorogood said there were failings in the hospital’s A&E department, on ward 7 and in the Acute Medical Unit.
He said they were attributable to ‘poor governance’ of Mid Staffordshire NHS Foundation Trust.
The court heard how cuts to staffing levels while the hospital was in pursuit of coveted Foundation Trust status had, at time, left just one senior nurse in charge of 84 beds.
“How far up does culpability go? It goes right up and is found in the body of the board itself,” he previously told the court.
Among the most shocking failings include a key 36-page care document critical for recording all patient information within the first 72 hours of admission – but just four pages had been filled in, the court heard.
Her fluid monitoring chart was incomplete, and records about food intake were contradictory –one said she was eating, another contained a referral to the dietician, which never happened.
Her patient number was wrongly written from one form to the next, forms were not signed by senior staff, and the ambulance crews’ record which contained important personal information was never attached to Mrs Astbury’s medical notes.
And the blood glucose monitoring chart nurses were supposed to fill in four times daily, was only partly completed - and sometimes not filled in at all.
Mr Thorogood also said that on one occasion a trainee nurse wrote down a very high blood sugar reading – 19.8 millimoles, but the senior nurse supervising told investigators she misheard the number and no action was taken. He added a diabetes specialist nurse also said the case was never brought to their attention, despite the senior admitting nurse stating the case ‘would have been passed on’.
Mr Thorogood added: “All clinical staff were working in the context of a poorly-led and poorly-ran system with no effective management, oversight or control.
“A tight ship runs well and the converse is demonstrated to be true.
“Nursing staff were set up to fail.”
Nurses Ann King was struck off and Jeannette Coulson was cautioned after a Nursing and Midwifery Council panel found them guilty of misconduct in July last year over the failures that led to Ms Astbury’s death. The trust pleaded guilty to a charge under the Health and Safety at Work Act brought by the Health and Safety Executive.
Defending the trust, Mr Stephen Climie apologised to Mrs Astbury’s family and her partner and carer Ron Street.
The trust has been dissolved by Health Secretary Jeremy Hunt because it is financially and clinically unsustainable – losing around £20 million a year, it has been revealed.
This recent court case took place at the end of April 2014 and it demonstrates how wide reaching health and safety law is in the workplace. This patient was admitted to hospital for treatment but died as a result of criminal negligence by a number of hospital staff.
Initially after the Health and Safety at Work Etc. Act 1974 came into force; hospitals themselves were given Crown Immunity from health and safety prosecutions. Directors, Managers, Supervisors and Employees could still be prosecuted for Health and Safety Breaches within the hospital, but the hospital as an organisation was exempt from such prosecutions.
These laws were completely revoked in 1990 with the National Health Service and Community Care Act 1990.
Hospitals, which had already, became Trusts before this date already came under the full force of the Health and Safety at Work Act, as they were funded by government but were theoretically financially independent of government and classed in law as independent organisations.
Now there are very few organisations who are exempt from Health and Safety Laws. The Ministry of Defence (MOD) is exempt under certain special circumstances and in a war zone. There have been successful prosecutions and litigation against the MOD though even in a war situation, where families felt their relatives had been given insufficient or substandard safety equipment.
So the law says that people and the management of any organisation cannot assume that the health and safety law is being followed in their workplace. Certain stringent proactive checks and verifications should be carried out as well as a thorough reactive investigations taking place when health and safety incidents (accidents, near misses and dangerous occurrences) do occur. Procedures should be updated and amended when it becomes apparent that the existing system is not working properly. Continuous improvement of policies and procedures is essential to any organisation, if health and safety risk in the workplace is to be maintained to a tolerable standard.