NHS trust fined £2.5m after two sepsis deaths
Patients were exposed to significant risk of avoidable harm
AN NHS trust has been fined more than £2.5 million over safety failings after an inquiry into the deaths of two patients at one of its hospitals in 2018.
The Dudley Group NHS Foundation Trust was prosecuted by the Care Quality Commission (CQC) following two separate incidents in which a mother-of-six and a 14-yearold girl, who were both suffering from sepsis, died after being “exposed to significant risk of avoidable harm”.
Natalie Billingham, 33, died at Dudley’s Russells Hall Hospital from multiple organ failure caused by a severe infection in March 2018.
A two-day hearing at Wolverhampton Magistrates’ Court was told teenager Kaysie-Jane Robinson, who had cerebral palsy, died in the same month after an inaccurate “early warning score” meant a sepsis screening tool was not triggered.
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.
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 firsthand 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.”
In a statement issued after the fine was imposed, the chief executive of The Dudley Group NHS Foundation Trust, Diane Wake, said: “We are deeply sorry that our care did not meet the standards Kaysie-Jane, Natalie and their families had a right to expect. We want to apologise and offer our sincere condolences again to the families.
“Although it will offer the families little comfort, we have learned from the failings that led to Kaysie-Jane and Natalie’s tragic deaths and made fundamental changes in the way our care is provided.”