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HSE to bring criminal prosecution over mismanagement of diabetic patient

Troubled Staffordshire health trust will face charges over treatment of diabetic woman who died in 2007

Blood test for diabetes photo: istock

4 September 2013

In an unusual move the Health and Safety Executive has announced that it will prosecute Mid Staffordshire NHS Foundation Trust following the death of diabetic patient Gillian Astbury in 2007.  The prosecution will be brought under s.3(1) of the Health and Safety at Work Act and follows an investigation by the HSE that has concluded that there is enough evidence, and that it is in the public interest to bring criminal proceedings in this case. The investigation was launched shortly after the publication of the Francis Report into events at Stafford Hospital which concluded that many hundreds of patients had died unnecessarily because of poor care and treatment at the hospital between 2005 and 2008.

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

"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.

"Our case alleges that the Trust failed to devise, implement or properly manage structured and effective systems of communication for sharing patient information, including in relation to shift handovers and record-keeping."

An inquest into Mrs Astbury's death recorded a narrative verdict but doncluded that a failure to administer insulin amounted to a gross failure to provide basic care. Last month, the Nursing and Midwifery Council (NMC) found two nurses guilty of misconduct for failing to spot Ms Astbury was . It ruled that Ann King and Jeannette Coulson had failed to look at or update Mrs Astbury's records and failed to carry out blood tests.

Mismanagement of diabetic patients

The careful management of patients with the chronic condition of both types of diabetes is essential if this type of tragedy is to be avoided. Clinical negligence lawyers at Leigh Day have represented a number of clients whose diabetes has fatally gone undiagnosed, or who have died following the poor care and treatment of their diabetic condition.

Medical negligence partner Suzanne White acted for the partner of a young man who was suffering from diabetic ketoacidosis and died when his GP failed to carry out a simple blood test for glucose, despite him presenting with the classic symptoms of diabetes including a lethargy, a great thirst, a raised pulse and hyperventilation. The clinical negligence team has also acted for a client who suffered brain damage after falling into a diabetic coma following a surgical procedure when medical staff failed to respond to tests showing that his blood sugar level was dropping. The team was also involved in a case when an elderly lady died following an overdose of insulin and neglect in her care in hospital.

Suzanne said:

“Time and again we see the tragic consequences of this disease when there is a failure by medical staff to provide even the most basic of medical care. My client’s partner died of diabetic ketoacidosis despite the clear symptoms of diabetes, but the GP dismissed these concerning symptoms, and my client was later found dead at home.

“In Mrs Astbury’s case there was a failure to even consider her previous medical history of diabetes, despite her being an in- patient in hospital.
“We welcome the decision by the Health and Safety Executive to bring criminal proceedings against Mid Staffordshire NHS Foundation Trust. We feel that lessons are not being learnt about the good management of diabetes, and hope that the threat of potential criminal proceedings against NHS Trusts will have a positive impact on care, and these cases will become a thing of the past.”

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