Shrewsbury and Telford Hospital NHS Trust admits failing to provide care in a safe way and exposing patients to a significant risk of avoidable harm after two patients die.
Mohammed Ismael Zaman (Bolly) bled to death at the Royal Shrewsbury Hospital in October 2019 while undergoing dialysis. A little over half a year later, in May 2020, 83-year-old Max Dingle was exposed to avoidable harm when his head was trapped between a bed rail and mattress before dying soon after from a cardiac arrest.
The Shrewsbury and Telford Hospital NHS Trust has been fined £1.3 million following criminal charges brought by the Care Quality Commission (CQC) at the Telford magistrates court in accordance with the Health and Social Care Act 2008. This comes months after the NHS trust was spotlighted following a damning independent review into poor maternity care.
Failures in Mohammed Ismael Zaman’s Care
Mr Zaman, a 31-year-old trainee pharmacist, was having kidney dialysis when his catheter became disconnected. His dialysis machine set off an alarm, but the hospital staff did not check to confirm the catheter was connected before resetting the alarm.
Within a span of 7 minutes, Mr Zaman lost 3 pints of blood (half of his blood supply), and he died despite attempts to save him.
The CQC, through their lawyer Ryan Donoghue, mounted the prosecution against the trust, saying failures in Mr Zaman’s care “were the legal cause of his death, for which the trust is responsible.” The court imposed an £800,000 fine on charges relating to Mr Zaman’s death.
Failures in the Care of Max Dingle
The Telford magistrates court also heard a charge brought against the trust by the CQC after the death of Max Dingle, a retired police officer.
Mr Donoghue told the court, Mr Dingle’s “head was trapped between the bed rails and mattress” on 3 May 2020 after he was admitted to the Royal Shrewsbury Hospital with chronic lung disease. Being overweight, Mr Dingle was placed in a larger bariatric bed that the hospital staff were not adequately trained to use. When the staff found him, his eyes were bulging, and he was purple. Mr Dingle was freed after an alarm was raised, but he later died from a cardiac arrest.
“The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm,” said Mr Donoghue.
My Dingle’s son, Phil Dingle, accused the trust of attempting to “whitewash” the circumstances behind his father’s death. “It is sad to lose a father at any stage in life, but more so in such tragic and preventable circumstances,” Phil Said.
“With many still unanswered questions, I find it incomprehensible that a hospital trust is allowed to ‘self-police’ a serious and unexpected incident which is highlighted as a known risk by the Health and Safety Executive. Furthermore, an independent Home Office coroner should be appointed in such circumstances to ensure transparency of process with the postmortem.”
The NHS trust was ordered to pay a fine of £533,334 over Mr Dingle’s death.
Exposing Patients to Significant Risk of Avoidable Harm
The CQC said the trust had “severely let down” Mr Dingle and Mr Zaman. According to Fiona Allinson, from the NHS care regulator, “People using health and social care services have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by Shrewsbury and Telford Hospital NHS Trust.”
In addition to the deaths of Mr Zaman and Mr Dingle, the NHS trust was accused of exposing other patients to a significant risk of avoidable harm.
Passing sentence on the case, Senior District Judge Paul Goldspring said the families of the two deceased patients had suffered “unimaginable grief.”
Following the hearing, the director of nursing at Shrewsbury and Telford Hospital NHS Trust, Hayley Flavell, said, “We are truly sorry for the pain and distress caused as a result of the failures in the provision of care…We offer our sincere apologies and heartfelt condolences to the families we let down.”
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