The Health and Safety Executive (HSE) confirmed on 11th April that it has launched a formal investigation into the circumstances of Gillian Astbury’s death at Stafford Hospital on 11th April 2007.
Mrs Astbury, 66, was admitted to Stafford Hospital after falling and fracturing her arm and pelvis. A diabetic who needed a daily injection, she was not administered insulin the day before her death. This was despite it being prescribed by doctors and her blood sugar levels being found to be very high, as a result she fell into a coma and ultimately died. A police investigation was subsequently launched but the Crown Prosecution Service ruled there was insufficient evidence to bring charges.
On the long six year period between the death and HSE commencing their investigation a spokesperson stated: “Following legal advice, HSE deferred a decision to pursue the investigation into Gillian Astbury’s death until the conclusion of the public inquiry, chaired by Robert Francis QC, into Mid Staffordshire NHS Trust.”
In the first report from the public inquiry, published in 2010, Robert Francis QC examined what he described as ‘shocking’ care at Stafford hospital and estimated between 400 and 1200 people died there between 2005 and 2009 as a result. An inquest jury at Stafford Coroner’s Court in 2010 ruled that the failure to administer insulin to Mrs Astbury amounted to a gross failure to provide basic care.
The second and final report published in February of this year contained key findings and a total of 18 recommendations after finding that patients were routinely neglected.
Speaking of the investigation the HSE spokesperson continued, “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 and Safety at Work Act.”
The investigation serves as a reminder that health and safety regulations are universal and not limited to those industries more traditionally associated with health and safety breaches and where investigations are more commonplace. It also highlights that even National Health Service providers, such as Mid Staffordshire NHS Foundation Trust, are not exempt from HSE investigation and such investigations (with the potential for criminal proceedings to ensue) may arise where the person to whom their has been “an exposure to risk of harm” is a patient in the process of receiving treatment, as opposed to an employee of the Trust, or a contractor. All organisations participating in the activity of delivering health care – or even welfare providers –should be mindful of the terms of section 3 of the Health and Safety at Work, etc Act 1974, which requires them to ensure that they are doing all that is reasonably practicable to ensure that those who may be affected by the conduct of their commercial activity are not exposed to risk of harm. There is no need for actual harm to have occurred – simply exposure to a risk of harm is sufficient to constitute a breach.
The launching of an investigation so many years after Ms Astbury’s death also serves as a reminder that the passage of time is not a factor in such investigations.