NHS Trust in Dudley fined £2.5m for 'safety failings' following deaths of two patients in 2018

An NHS trust in Dudley has been fined more than £2.5 million over safety failings after an inquiry into the deaths of two patients at one of its hospital in 2018.

The Dudley Group NHS Foundation Trust was prosecuted by the Care Quality Commission (CQC) following two separate incidents involving a mother-of-six and a 14-year-old girl.

Natalie Billingham, 33, and 14-year-old Kaysie-Jane Robinson were both suffering from sepsis and died after being "exposed to significant risk of avoidable harm".

Ms Billingham died at Dudley’s Russells Hall Hospital from multiple organ failure caused by a severe infection in March 2018.

Teenager Kaysie-Jane, who had cerebral palsy, died in the same month after an inaccurate "early warning score" meant a sepsis screening tool was not triggered, a two-day hearing at Wolverhampton Magistrates’ Court was told.

The court heard the teenager, who died six days later after being transferred to another hospital, was initially believed to have gastroenteritis.

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.

District Judge Wilkinson said the deaths occurred after the trust "failed to act swiftly and decisively" to concerns raised by the CQC after inspections prior to the deaths.

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.

The judge, who conceded that improvements in care had been made since the “dark days” of 2018, said one of the offences had caused the death of Kaysie-Jane.

The judge told the court: "Every patient that attends (an emergency department) has a right to expect that the care they receive will be safe."

Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on February 28 2018 and died on March 2 of organ failure caused by a “time critical” infection, the court heard.

The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations.

The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored".

Mr Wilkinson, who conceded that improvements in care had been made since the “dark days” of 2018, said: "To hear direct from the mothers of both victims and to witness first-hand 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.

“It failed to act swiftly and decisively to the concerns raised by the CQC – those concerns themselves warned that lives and patient safety were at risk."

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 Kaysie-Jane and Natalie’s families."