Hospital Trust’s basic failures led to patient’s death

A vulnerable diabetic patient died because a hospital trust failed to implement basic handover procedures and ensure essential record-keeping, a court has heard.

Staff at Stafford Hospital did not follow – sometimes even look at – medical notes that clearly stated Gillian Astbury needed insulin, regular blood tests and a special diet.

A system for communicating patient needs at staff handovers was ‘inconsistent and sometimes non-existent’ the trust itself admitted. Record-keeping and monitoring of patient care plans were also far below acceptable standards.

Specific to the care of Ms Astbury, 66, a Type 1 diabetic, mistakes were made at up to eight shift changes and as many as 11 drugs rounds. The failure to administer insulin was the direct cause of her death.

The Health and Safety Executive investigated, in line with its policy to investigate deaths that occur in the health sector where there is evidence that clear standards have not been met because of a systematic failure in management systems.

Mid Staffordshire NHS Foundation Trust was prosecuted by HSE and pleaded guilty to an offence under the Health and Safety at Work etc Act. At Stafford Crown Court, it was today fined £200,000 and ordered to pay £27,049 costs.

Peter Galsworthy, HSE Head of Operations in the West Midlands, said:

“Mid Staffordshire NHS Foundation Trust failed to implement a proper handover system, or to oversee the proper completion of nursing records and the monitoring of care plans. In doing so they put Gillian Astbury at risk.  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.

“Gillian Astbury and her loved ones were failed by Mid Staffordshire NHS Foundation Trust. Every hospital patient has the right to expect more. Serious safety management flaws were identified by our investigation. We expect lessons to be learned across the NHS to prevent this happening again.”

At court today, 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.”

Notes to Editors:

  1. 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.
  2. 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.
  3. Gillian Astbury died on 11 April 2007, of diabetic ketoacidosis, when she was an in-patient at the hospital. The immediate cause of death was the failure to administer insulin to a known diabetic patient. She had been admitted to the hospital on 1 April 2007, with fractures to her arm and pelvis.
  4. Mid Staffordshire NHS Foundation Trust has been the subject of two major inquiries, the first private and the second public, into events at Stafford Hospital between 2005 and 2009. The findings of the public inquiry, led by Robert Francis QC, are at
  5. HSE explains when it may and when it is unlikely to investigate in the health sector in its ‘who regulates’ pages of the HSE website
  6. HSE news releases are published at and tweeted @H_S_E

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