The Mid Staffs NHS Trust pleaded guilty to breaching the health and safety laws after a diabetic patient died in its care.
The 66 year old woman was admitted to hospital in April 2007 after fracturing her arm and pelvis but nurses failed to check her blood sugar levels and the patient slipped into a diabetic coma. An inquest in 2010 found that two nurses failed to give her insulin which resulted in her death.
The judge at Stafford Crown Court said,
“This was a wholly avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it”
“As repeated investigations have revealed, there was a systemic failure at Stafford Hospital in relation to two of the most basic tenets of patient care: proper hand-overs between nursing shifts, and proper record-keeping.
The dead woman’s friend and carer Ron Street said he was upset that the HSE had not prosecuted the line managers in charge at the time who he felt were also culpable for her death.
A Health and Safety Executive spokesperson said: “The Trust’s systems were simply not robust enough to ensure that staff consistently followed principles of good communication and record keeping. Gillian’s death was entirely preventable. She just needed to be given insulin.”
“We expect lessons to be learned across the NHS to prevent this happening again.”
The Nursing and Midwifery Council panel found the two nurses concerned guilty of misconduct and one nurse was subsequently struck off and the other cautioned. Mid Staffordshire Trust was fined £200,000 and also ordered to pay £27,000 in costs.
The HSE confirmed it was investigating two more deaths at the hospital – two women, one who died in 2008 and another in July 2013.
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