A systematic failing to provide adequate nursing facilities
along with low staffing levels contributed to the death of a woman
with
diabetes at a hospital racked by scandal, an inquest jury has
ruled.
The failure to administer insulin to 66-year-old Gillian Astbury
amounted to a gross failure to provide basic care, the jurors
declared.
Mrs Astbury slipped into a fatal diabetic coma at Stafford
Hospital. She died early on April 11, 2007, while being treated for
fractures to her arm and pelvis.
Other contributing factors to Mrs Astbury's death, included the
failure of nursing staff to record glucose levels, communicate
properly with each other and read clinical notes, the 10-member
panel said, as it returned a narrative verdict after a two-day
inquest.
In its verdict, the jury said: "Nursing facilities were poor,
staff levels were too low, training was poor, and record-keeping
and communications systems were poor and inadequately managed."
The jury, sitting at Stafford's County Buildings, heard that the
pensioner's blood sugar levels were not properly monitored and
insulin was not administered on the day before her death, despite
being prescribed by doctors.
The court heard that some of the nursing staff were not informed
that Mrs Astbury, from Hednesford, was diabetic and some said they
were too busy to check the patient notes at the foot of her
bed.
Antony Sumara, chief executive of the hospital, has apologised
for Mrs Astbury's care and the local NHS trust has admitted full
liability in separate civil proceedings.