CQC prosecutes the Dudley Group NHS Foundation Trust following two patient deaths

Published: 19 November 2021 Page last updated: 19 November 2021

The Dudley Group NHS Foundation Trust has been fined over £2.5 million after pleading guilty to failing to provide safe care and treatment to two patients, causing them avoidable harm, following a sentencing hearing today (Friday 19 November) at Wolverhampton Magistrates’ Court.

Natalie Billingham, a 33-year-old mother of six, was admitted to the trust’s Russells Hall Hospital, Dudley, on 28 February 2018 after suffering a week of worsening swelling and pain in her right foot.

She died at the hospital two days later from multiple organ failure caused by severe infection.

Kaysie-Jane Bland (also known as Kaysie-Jayne Robinson), a 14-year-old girl who lived with several complex health conditions from birth, was admitted to the hospital on 4 March 2018 with diarrhoea and vomiting.

In the early hours of the following morning, she was transferred to Birmingham Children’s Hospital where she remained until her death, caused by a build-up of fluid on her brain and sepsis, five days later.

The care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which CQC repeatedly raised with the trust in the months before their deaths. However, the trust did not take all reasonable steps to make improvements, despite CQC’s intervention.

These failings include the trust’s management of patients at risk of developing sepsis, which was not diagnosed and treated in accordance with national standards for Natalie or Kaysie-Jane.

Each patient's case was considered as an individual offence, for which the trust was fined £1,266,666. This leads to a total fine of £2,533,332 for the two offences.

The court also ordered the trust to pay £38,000 costs to the Care Quality Commission (CQC), which prosecuted these criminal offences.

Fiona Allinson, CQC deputy chief inspector of hospitals, said:

“Natalie and Kaysie-Jane’s deaths are tragedies. My thoughts are with their families and all those grieving their loss.

“People have a right to safe care and treatment, so it is unacceptable that patient safety was not well managed by the trust.

“Had the trust addressed failings we identified before Natalie and Kaysie-Jane died, they would have received better care which could have saved their lives.

“The vast majority of people receive good care when they attend hospital, but if we find a provider has put people in its care at risk of harm, we take action to hold it to account and protect people.

“I hope this prosecution reminds care providers they must always take all reasonable steps to ensure people’s safety, including responding appropriately when our inspections identify areas needing improvement.”

CQC brought this prosecution after it found Natalie and Kaysie-Jane were not protected from avoidable harm at Russells Hall Hospital.

Errors in the hospital’s initial assessments of both patients undermined its understanding their needs and delayed its response to their conditions. This included failings in its implementation of the trust’s sepsis pathway.

There were also failings in how both patients were monitored, and how information was captured about their conditions to inform decisions about their care. This hindered the timely escalation of concerns.

The gravity of these failings is worsened by the trust’s inaction following CQC’s interventions before their deaths.

This includes following an unannounced inspection of Russells Hall Hospital’s urgent and emergency services three months before Natalie and Kaysie-Jane died, when CQC raised concerns regarding sepsis management, patient observations and overcrowding in the department.

Although this insight, which was communicated to the trust, would have helped it improve patient safety, it did not respond adequately to protect people from avoidable harm.

Medical experts agree that the safety failings caused Kaysie-Jane’s death.

It is not agreed by medical experts that Natalie’s death was caused by those failings, although there is agreement that the treatment she received did not meet the required standard.

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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.