Basic failings in hospital care of diabetic patient Gillian Astbury revealed

More details about the poor care of a diabetes patient by staff at Stafford Hospital, which led to her death, were revealed last week at a sentencing hearing at Stafford crown court.
Gillian Astbury was 66 years old when she passed away at the Mid Staffordshire NHS Foundation Trust-run hospital in April 2007 after failing to receive the insulin injections she needed.
An inquest into her death ruled that low staffing levels and other systemic failures at Stafford hospital were contributing factors, and that a failure to administer insulin to the 66-year-old amounted to a gross failure to provide basic care. An independent report also concluded last year that basic failings in standards of care led to an unusually high number of patient deaths at the hospital between 2005 and 2008.
In August 2013, three years after the inquest rulings, it was announced that the troubled Mid Staffordshire NHS Trust would be prosecuted over Astbury’s death, after the trust admitted breaching health and safety regulations at a hearing at Stafford Magistrates’ Court.
The case was moved to Stafford Crown Court last Friday and during the proceedings, Bernard Thorogood, prosecuting, said Astbury had been let down by the “complete absence” of proper systems of handover between nurses, poor record-keeping and communication between wards and clinicians in place at that time. “In short, the nursing staff were set up to fail.”
Astbury was admitted to A&E at Stafford Hospital with a suspected fractured arm and pelvis on 1 April 2007 following a fall. Thorogood revealed that during the short time she was in hospital, staff made a catalogue of errors.
Key information about the “brittle” type 1 diabetic from the ambulance crew was not passed on following her admission; her fluid monitoring chart was not completed and records about food intake were contradictory; her patient number was wrongly written from one form to the next; forms were simply not signed by senior staff; and on the morning of 10 April 2007, two nurses failed to give her daily dose of insulin. She lapsed into a coma and later died in the early hours of the following morning.
Mid Staffordshire NHS became the first foundation trust to go into administration in April 2013 and now faces an unlimited fine, although sentencing of the trust has been delayed to a later date.