Catalogue of hospital failings in tragedy of diabetic

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A DIABETIC patient who died at scandal-hit Stafford Hospital was let down by poor record-keeping and an inadequate system for the handing over of patients between different shifts and wards, a court heard yesterday.

Fresh details emerged over the poor care received by 66-year-old Gillian Astbury as a judge at Stafford Crown Court began considering the sentence to be imposed on the Mid Staffordshire NHS Foundation Trust.

Mrs Astbury died at hospital in April 2007 after two nurses failed to give her insulin.

The trust last year admitted breaching health and safety 
regulations after the Health and Safety Executive brought a prosecution over Mrs Astbury’s death last year.

Mid Staffs has already apologised for the “dreadful” care Mrs Astbury received in the short time she was at the hospital, during which time she was transferred between three different wards and has said practices have “improved considerably” in the intervening years.

Bernard Thorogood, prosecuting, said the basic failings began right after Mrs Astbury was admitted to accident and emergency with a suspected fractured arm and pelvis following a fall on April 1, 2007.

Mr Justice Haddon-Cave was told that an initial admission process had been carried out correctly, but failings in subsequent handovers meant key information about Mrs Astbury was not then passed on.

Described as a “brittle” Type-1 diabetic, she needed daily injections of slow-acting insulin to control her blood sugar and the admitting doctor made a proper assessment of her condition, also setting a trigger level under which her blood glucose should be kept, according to Mr Thorogood.

He said the admitting A&E nurse who initially assessed Mrs Astbury properly recorded her diabetes, her need for a dietician, and came up with a care plan – proving the hospital’s staff should have been well aware of her condition.

“However, before these arrangements could be set up there needed to be a robust handover system,” added Mr Thorogood.

She was transferred from A&E to the hospital’s Ward 7 on April 1, but by the time of her death in the early hours of April 11, had been the victim of a catalogue of errors.

Nurses failed to give her daily dose of insulin on the morning of April 10, and she collapsed and later died in the early hours of the following morning.

Among the failings, 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 was never acted upon.

Her patient number was wrongly written from one form to the next, forms were not signed by senior staff, while on admission the ambulance crews’ record –containing key information – was never attached to Mrs Astbury’s medical notes.

In one case, the ward where Mrs Astbury was when she died was using an obsolete form

Mr Justice Haddon-Cave said the case had “wider implications” and he wanted to “reflect on the submissions”. The Trust will be sentenced at a later date.

Last year, the Francis Report into the trust concluded there had been basic failings in standards of care at Stafford, with hundreds more patients dying than would have been expected between 2005 and 2008.