Mid Staffordshire Foundation Trust has been fined £200,000 for the “wholly avoidable” death of a diabetic patient.
The trust pleaded guilty earlier this year for failing to ensure the safety of Gillian Astbury, who died at the trust in 2007 after staff repeatedly failed to give her insulin.
At Stafford Crown Court today the trust was fined £200,000 and ordered to pay £27,049 costs.
The court heard there were failings in Ms Astbury’s care during at least eight shift handovers and 11 drugs rounds. The Health and Safety Executive, which brought the prosecution, said in some cases staff had failed to even look at Ms Astbury’s patient notes.
Mr Justice Haddon-Cave said: “It was a wholly avoidable and tragic death of a vulnerable patient admitted to hospital for care but who died because of a lack of it.
He added: “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 poor care received by Ms Astbury was one of a number of cases highlighted by the Francis inquiry into poor care at the trust.
Two nurses involved in Ms Astbury’s care were found guilty of misconduct in relation to the case by the Nursing and Midwifery Council.
However, the Crown Prosecution Service has previously ruled there was insufficient evidence to support manslaughter charges against any individuals.
The HSE has faced criticism for the length of time it has taken the case to be resolved. During the Francis inquiry the regulator admitted it was unable to fulfill its legal obligation to investigate deaths believed to have been caused by “clinical decisions about diagnosis or treatment”, due to a lack of resources.
In a statement released on Monday the HSE said its policy was to investigate deaths in the health sector “where there is evidence that clear standards have not been met because of a systematic failure in management systems”.
Peter Galsworthy, HSE head of operations in the West Midlands, 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.
He added: “We expect lessons to be learned across the NHS to prevent this happening again.”
Trust deputy chief executive Jeff Crawshaw said: “On behalf of the Trust, I want to again express our deepest and most sincere apologies to Mrs Astbury’s family for the unacceptable care she received at Stafford Hospital in 2007.
“Today marks the final stage in what has been a thorough and long running investigation into the failings which led to her tragic death.
“From the very beginning, we have acknowledged the failings in Mrs Astbury’s care, and we have never shied away from our responsibility for what happened to her.
“It has been recognised by all sides in this distressing case that our Trust is a very different and much better organisation now than it was when this tragedy occurred.”
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Mid Staffs fined over 'avoidable' death