On 11 April 2013, the HSE announced a formal investigation into the circumstances of the death of Gillian Astbury at Stafford Hospital in April 2007. Mrs Astbury, who was diabetic, was admitted to Stafford Hospital in April 2007 after a minor fall and was being treated for fractures to her arm and pelvis. An inquest in 2010 heard that Mrs Astbury’s blood sugar levels were not properly monitored and insulin was not administered on the day before her death – despite being prescribed by doctors – causing her to fall into a diabetic coma and die aged 66. A police investigation was launched after her death, but the CPS concluded that there was insufficient evidence to bring charges.
The inquest jury in 2010 returned a narrative verdict, indicating that the failure by nursing staff to record glucose levels, communicate effectively and read clinical notes contributed to her death. Connected to this, a public inquiry, chaired by Robert Francis QC, was launched in relation to Stafford Hospital following estimates that between 400 and 1,200 people died there between 2005 and 2009. A final report from the public inquiry, published in February 2013, concluded that patients were routinely neglected and made a number of key findings and recommendations.
A spokesman for the HSE said:
“Following legal advice, HSE deferred a decision to pursue the investigation into Gillian Astbury’s death until the conclusions of the public inquiry, chaired by Robert Francis QC, into Mid Staffordshire NHS Foundation Trust.”
The HSE also said that:
“Our focus will be on establishing whether there is evidence of the employer (the Trust) or individuals failing to comply with their responsibilities under the Health & Safety at Work Act.”
The announcement of this investigation serves as a timely reminder that even NHS (or private practising medical) providers can be subject to HSE investigations. The aim of the HSE is to safeguard members of the public, who may be exposed to risks from the way that work is carried out. HSE investigations are not limited to construction industries or others more commonly associated with health and safety breaches. If a patient has been exposed to a “risk of harm” whilst receiving treatment, then the medical provider may become subject to a HSE investigation, with the potential for subsequent criminal prosecutions.
Whilst the HSE might not routinely investigate medical providers for isolated deaths or untoward patient incidents, this announcement reminds us that the HSE is prepared to intervene in individual cases where there appears to be a series of underlying incidents or adverse trends, notwithstanding that a death might have occurred many years ago.