Four patients lost their lives because a lack of safety procedures at Mid Staffordshire NHS Foundation Trust resulted in careless and unnecessary failings.
The Health and Safety Executive (HSE) investigated the deaths of four patients between 2005 and 2014 at Cannock and Stafford Hospitals. The Trust managed both hospitals.
The breaches of health and safety law in regards to two of the four deaths (Jean Tucker in 2005 and Ivy Bunn in 2008) were found during two inquiries into events at Stafford Hospital between 2005 and 2009. HSE prosecuted Mid Staffordshire Hospital Trust in 2014 for the death of Gillian Astbury, who died in April 2011.
A further two cases (Joy Bourne 2013 and Patrick Daly in 2014) were brought to HSE’s attention after the Francis Inquiry where the Trust had been found to have broken the law.
Mid Staffordshire NHS Foundation Trust (MSFT) was placed into special administration and ceased to provide health care services on 31 October 2014.
Three of the patients suffered falls that led to their deaths and a fourth, Jean Tucker, suffered a severe anaphylactic reaction after being given penicillin, despite having informed the hospital on several occasions that they were allergic to it.
The Health and Safety Executive investigated the Trust, in line with its policy to investigate deaths that occur in the health sector where there is evidence that clear standards had not been met because of a systematic failure in management systems.
Mid Staffordshire NHS Foundation Trust was prosecuted by HSE and pleaded guilty to breaching the Health and Safety at Work etc Act 1974 in relation to all four patients.
At Stafford Crown Court, it was today fined £500,000 and ordered to pay £35,517.34 costs.
HSE principal inspector in the West Midlands, Wayne Owen, said: “The deaths of Jean, Ivy, Joy and Patrick were preventable. Mid Staffordshire NHS Foundation Trust failed them and their loved ones.
“The Trust failed to follow a number of its own policies in relation to handing over information, completing records, carrying out falls risk assessments and the monitoring of care plans. These systems were not robust enough to ensure they were followed consistently and correctly.
“It is in the public interest that any hospital Trust is held accountable for serious breaches of the law resulting in death or life-changing harm. We expect lessons to be learned across the NHS to prevent tragedies like the losses of these four lives from happening again.”
The families of the four victims collectively provided a statement: “We all expected our loved ones to return home from Stafford Hospital having had the correct care and treatment and their lives should not have ended when they did. It has been a harrowing experience to know that they died in an unhappy and undeserved manner.
“Some basic rules had not been adhered to and the level of care was simply not good enough.
“We acknowledge the Trusts unreserved apologies and the conclusion of this case goes some way to bringing the closure that we all need. It is hoped that lessons will be learned across the whole NHS to ensure hospitals do not put other families through the same terrible ordeal.”
Notes to editors:
- The Health and Safety Executive is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. hse.gov.uk
- Mid Staffordshire NHS Foundation Trust pleaded guilty to an offence under Section 3(1) of the Health and Safety at Work Act 1974. This states that every employer has a duty to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected by the conduct of his undertaking are not as a result exposed to risks to their health and safety.
- HSE explains when it may, and when it will not, investigate in the health sector in its ‘who regulates’ pages of the HSE website http://www.hse.gov.uk/healthservices/arrangements.htm