NHS trust fined £2.5m over deaths of two A&E patients

‘It is clear that had the trust reacted to the concerns of the CQC in a timely fashion then this double tragedy may not have unfolded’

Shaun Lintern
Health Correspondent
Friday 19 November 2021 21:36
<p>CQC inspectors were ‘clearly shocked’ by conditions during their visits to Russells Hall Hospital before the deaths </p>

CQC inspectors were ‘clearly shocked’ by conditions during their visits to Russells Hall Hospital before the deaths

An NHS hospital has been fined more than £2.5m following safety failings in its A&E department that led to the deaths of two patients.

The Dudley Group NHS Foundation Trust pleaded guilty earlier this week and was sentenced on Friday for failings involved in the deaths of a mother of six and a 14-year-old girl, who were both suffering from sepsis.

It is the first ever prosecution of a hospital trust for failings in A&E and comes at a time when hospitals across the country are seeing record levels of A&E patients. A report this week said more than 4,500 may have died as a result of long waits in A&E.

A two-day hearing at Wolverhampton Magistrates' Court was told Natalie Billingham, 33, died at Dudley’s Russells Hall Hospital from multiple organ failure caused by a severe infection in March 2018.

Teenager Kaysie-Jane Robinson, who had cerebral palsy, died after an inaccurate “early warning score” meant a sepsis screening tool was not triggered.

She was transferred to Birmingham Children’s Hospital where she remained until her death, caused by a build-up of fluid on her brain and sepsis, five days later.

The prosecution was brought by the care watchdog the Care Quality Commission over the trust’s failure to protect patients from “significant risk of avoidable harm”.

The CQC said the care both patients received was undermined by the trust’s failure to address known safety failings, which had been repeatedly raised in the months before the deaths.

These failings included the trust’s management of patients at risk of developing sepsis, which was not diagnosed and treated in accordance with national standards for Natalie or Kaysie-Jane.

The trust admitted two breaches of the 2008 Health and Social Care Act.

Passing sentence on the trust, District Judge Graham Wilkinson fined it £2,533,332 and ordered it to pay a £38,000 contribution to the costs of the prosecution.

Mr Wilkinson, who conceded that improvements in care had been made since the “dark days” of 2018, said: “We have all now heard and been deeply moved by the victim personal statements.

“To hear direct from the mothers of both victims and to witness first-hand both their distress and bravery is something that I doubt any present will ever forget.

“I have been informed that it is the first prosecution ever of any trust for failings within an emergency department.

“One of the most significant features of the case when considering culpability was that the trust had been inspected by the CQC in a series of unannounced visits during the months preceding this tragedy.

“What was found on each occasion clearly shocked the inspecting team of healthcare professionals. It was against this backdrop that Natalie and Kaysie-Jane were failed by the trust.

“It is clear that had the trust reacted to the concerns of the CQC in a timely fashion, then this double tragedy may not have unfolded.”

Fiona Allinson, CQC deputy chief inspector of hospitals, said: “Natalie and Kaysie-Jane’s deaths are tragedies. My thoughts are with their families and all those grieving their loss.

“People have a right to safe care and treatment, so it is unacceptable that patient safety was not well managed by the trust.

“I hope this prosecution reminds care providers they must always take all reasonable steps to ensure people’s safety, including responding appropriately when our inspections identify areas needing improvement.”

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