Stafford Hospital was this afternoon fined £200,000 over 'systemic failings' that killed diabetic pensioner Gillian Astbury.
Mid Staffordshire NHS Foundation Trust admitted breaching health and safety law which saw the 66-year-old fall into a coma and die and nurses failed to administer crucial insulin injections.
At Stafford Crown Court today High Court judge Mr Justice Haddon-Cave said the case was "a wholey avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it."
Stafford Crown Court heard her death came as a consequence of bosses having 'no control' over the hospital.
Mrs Astbury from Hednesford was first admitted into Stafford Hospital on April 1, 2007 after breaking her arm and pelvis after suffering falls at Cannock Hospital and at home.
She died in the early hours of April 11 after lapsing into a fatal diabetic coma because two nurses failed to give her the required insulin injections.
But Stafford Crown Court heard it was not a one-off oversight that led to her death but a series of repeated failures to share information, hold proper staff hand-overs and keep records over eight nurse shifts and up to 11 drug rounds.
Prosecutor Mr Bernard Thorogood said there were failings in the hospital’s A&E department, on ward 7 and in the Acute Medical Unit.
He said they were attributable to ‘poor governance’ of Mid Staffordshire NHS Foundation Trust.
The court heard how cuts to staffing levels while the hospital was in pursuit of coveted Foundation Trust status had, at time, left just one senior nurse in charge of 84 beds.
“How far up does culpability go? It goes right up and is found in the body of the board itself,” he previously told the court.
Among the most shocking failings include a key 36-page care document critical for recording all patient information within the first 72 hours of admission – but just four pages had been filled in, the court heard.
Her fluid monitoring chart was incomplete, and records about food intake were contradictory –one said she was eating, another contained a referral to the dietician, which never happened.
Her patient number was wrongly written from one form to the next, forms were not signed by senior staff, and the ambulance crews’ record which contained important personal information was never attached to Mrs Astbury’s medical notes.
And the blood glucose monitoring chart nurses were supposed to fill in four times daily, was only partly completed - and sometimes not filled in at all.
Mr Thorogood also said that on one occasion a trainee nurse wrote down a very high blood sugar reading – 19.8 millimoles, but the senior nurse supervising told investigators she misheard the number and no action was taken. He added a diabetes specialist nurse also said the case was never brought to their attention, despite the senior admitting nurse stating the case ‘would have been passed on’.
Mr Thorogood added: “All clinical staff were working in the context of a poorly-led and poorly-ran system with no effective management, oversight or control.
“A tight ship runs well and the converse is demonstrated to be true.
“Nursing staff were set up to fail.”
Nurses Ann King was struck off and Jeannette Coulson was cautioned after a Nursing and Midwifery Council panel found them guilty of misconduct in July last year over the failures that led to Ms Astbury’s death. The trust pleaded guilty to a charge under the Health and Safety at Work Act brought by the Health and Safety Executive.
Defending the trust, Mr Stephen Climie apologised to Mrs Astbury’s family and her partner and carer Ron Street.
The trust has been dissolved by Health Secretary Jeremy Hunt because it is financially and clinically unsustainable – losing around £20 million a year, it has been revealed.