Two patients suffering from sepsis died following treatment at the same NHS hospital after inspectors’ warnings about failings in care were not acted upon, a court has heard.
Wolverhampton Magistrates’ Court was told the Care Quality Commission (CQC) informed the Dudley Group NHS Foundation Trust that its staff were not clear on how to follow a sepsis treatment “pathway” in the months leading up to both deaths.
The trust pleaded guilty at a previous hearing to safety failings posing a “significant risk of avoidable harm” following the deaths of mother-of-six Natalie Billingham, 33, and 14-year-old Kaysie-Jane Robinson in March 2018.
A lawyer acting for the Dudley Group NHS Foundation Trust admitted two breaches of the 2008 Health and Social Care Act on the trust’s behalf in July after an investigation by the CQC.
The charges admitted by the trust stated that it had failed to provide treatment in a safe way, resulting in harm, in February and March 2018.
Opening the facts of the case on Thursday, the CQC’s barrister, Ian Bridge, said 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 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”.
In the case of Kaysie-Jane, who had cerebral palsy, an “early warning score” was inaccurate, meaning a sepsis screening tool was not triggered.
The court heard the teenager, who died six days later after being transferred to another hospital, was initially believed to have gastroenteritis.
Mr Bridge, who described sepsis as a “stealthy and vicious” condition, added: “In the months leading up to these two tragic cases, the Russells Hall Hospital had been the subject of a series of unannounced inspection visits by the Care Quality Commission.”
Unacceptably poor standards of care and treatment had been identified, Mr Bridge said, which were directly related to the “failings which were present in both of these cases”.
Mr Bridge added: “The visits are documented at length in the witness statements.
“The statements also document correspondence and action taken in consequence of their findings.”
Concerns in relation to sepsis management and patient monitoring had been raised during the inspections, the court heard.
Mr Bridge added that a letter sent by the CQC had informed the trust that “staff were not clear on how to follow the sepsis pathway”.
The failures, the CQC’s counsel said, were brought to the attention of the trust “in a rapid fashion” but they were not acted upon.
Victim impact statements were read to the court on behalf of Ms Billingham’s brother, as well as her mother Marina Tranter, who described her as the “core of our family” and “my best friend and a wonderful mum to six beautiful children”.
Mrs Tranter told the hearing: “She is missed immensely by everyone who knew her.
“There are no words to describe what it’s like to lose your child.”
Kaysie-Jane’s mother, Jane Robinson, also addressed the court, reading out a statement from her own mother, who remembered her granddaughter as an “amazing and cheeky” little girl who had brought “so much joy and magical moments” to her family.
Reading her own statement, Ms Robinson said: “Kaysie was my first-born child. From the moment she entered the world she meant everything to me.”
Kaysie-Jane had been a “ray of sunshine” who had shown that “disability was a label that did not define her,” her mother said.
Ms Robinson added: “When Kaysie passed so much of me died with her… my hope and my inspiration.
“I feel guilty that I couldn’t save her. I feel they didn’t treat her like she mattered. A system I had faith in took her from me.”
Ms Robinson said she had had to “deal with finding the truth” for three years, causing her unbearable stress on top of the pain of losing her daughter.
The Trust’s lawyer, Paul Spencer, told the court financial compensation settlements had been reached with both families.
The current management of the trust were determined to drive through change, Mr Spencer said.
“These are two tragic and unnecessary patient deaths,” Mr Spencer said. “The Trust recognises that it is going to face a very substantial fine.”
The trust is due to be sentenced on Friday afternoon.
It said in a statement issued last summer that it was “deeply sorry” that its care did not meet the high standards Kaysie-Jane and Natalie and their families had a right to expect, and “did not reflect the values of our trust”.