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.
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.
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.
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