Stafford NHS Trust fined £200,000
The NHS Trust which runs Stafford Hospital has been fined £200,000 after admitting basic failings in care which led to the death of patient in 2007.
A judge sitting at Stafford Crown Court said the death of Gillian Astbury, who was not given insulin despite being diabetic, had been caused by an "effectively broken" system for hand-overs between staff and poor record-keeping.
Passing sentence on the Mid Staffordshire NHS Foundation Trust, High Court judge Mr Justice Haddon-Cave described the 66-year-old's death as tragic and wholly avoidable.
Mrs Astbury, from Hednesford, Staffordshire, died in the early hours of April 11 2007 after lapsing into a diabetic coma while being treated for fractures to her arm and pelvis.
The Trust, which was also ordered to pay £27,000 in costs, pleaded guilty to breaching health and safety law last October at Stafford Magistrates' Court, having previously apologised for its "dreadful" care of Mrs Astbury.
In his sentencing remarks, Mr Justice Haddon-Cave said responsibility for the failures at the time of Mrs Astbury's death lay with senior managers at the Trust, which was criticised by a public inquiry for the "routine" neglect of patients between 2005 and 2009.
The judge said: "This was a wholly avoidable and tragic death of a vulnerable patient who was admitted to hospital for care but died because of the lack of it.
"As repeated investigations have revealed, there was a systemic failure at Stafford Hospital in relation to two of the most basic tenets of patient care: proper hand-overs between nursing shifts, and proper record-keeping.
"These failures put legions of patients at Stafford Hospital at serious risk.
"The simple fact is that Mrs Astbury died because she was not given the insulin that she needed."
Among five aggravating features of the case identified by the judge was the fact that they occurred amid a "general malaise" in standards and priorities at Stafford Hospital between 2004 and 2007.
The judge said: "The underlying causes of the breaches and the malaise were fundamental organisational and managerial failures, which can be traced to the very top of the organisation."
In assessing the size of the fine, the judge accepted that the Trust had shown a high degree of co-operation with the authorities, and had been "entirely candid" about its failures.
The court heard that the hospital had undergone radical change since Mrs Astbury's death.
The entire senior management in post at the time of the death no longer work at the Trust, which is set to be dissolved later this year.
The criminal investigation into Mrs Astbury's death found that staff at the hospital did not follow, or sometimes even look at, medical notes that clearly stated she needed insulin, regular blood tests and a special diet.
Commenting after the fine was imposed, Peter Galsworthy, the Health and Safety Eexecutive's 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.
"We expect lessons to be learned across the NHS to prevent this happening again."
Jeff Crawshaw, deputy chief executive of Mid Staffordshire NHS Foundation Trust, 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."