CQC prosecutes Shrewsbury and Telford Hospital NHS Trust following two patient deaths

Published: 19 May 2022 Page last updated: 19 May 2022

Shrewsbury and Telford Hospital NHS Trust has been ordered to pay a total of £1,375,712 after pleading guilty to failing to provide safe care and treatment to two patients, causing them avoidable harm, as well as exposing other patients to a significant risk of avoidable harm, following a sentencing hearing today (Wednesday 18 May) at Telford Magistrates’ Court.

Mohammed Ismael Zaman (known as Bolly) attended the Royal Shrewsbury Hospital to receive dialysis on 18 October 2019.

When a patient receives dialysis, their connection lines must always be visible however, this did not happen in this case. The trust also failed to ensure that their staff were adequately trained to follow best practice guidelines regarding the connection lines being secured to his bed, which may have resulted in them becoming disconnected.

He was found by staff bleeding heavily from a disconnected line, resuscitation was attempted but was unsuccessful, sadly Bolly died.

Max Dingle was admitted to the Royal Shrewsbury Hospital on 27 April 2020 due to shortness of breath and a high temperature. On 28 April 2020, he was assessed as requiring a specialist bariatric bed.

On 3 May 2020, Max was found trapped in the bariatric bed and died shortly afterwards. The trust failed to train staff in the setting up of bariatric beds and this led to the entrapment of Max.

Shrewsbury and Telford Hospital NHS Trust did not take all reasonable steps to ensure that safe care and treatment was provided, resulting in the most serious avoidable harm possible, to two patients and the exposure of harm to other patients at the Royal Shrewsbury Hospital.

Each case was considered as an individual offence, for which the trust was fined £800,000 for Bolly's case and £533,334 for Max's case. This leads to a total fine of £1,333,334. The court also ordered the trust to pay £42,378 costs to the Care Quality Commission (CQC), which brought this prosecution.

There are a number of enforcement actions we can and will take before prosecution to encourage and support improvement. People are entitled to receive safe care and treatment when they put their trust in health and care services, and providers should be held to account when significant avoidable failures occur.

The size of the fine is a decision made by the court and is informed by sentencing guidelines. CQC does not have influence over this decision.

Fiona Allinson, director of operations - Midlands network, said:

“Both of these deaths are a tragedy. My thoughts are with the families of Bolly and Max, and others grieving for their loss.

“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.

“Both patients were severely let down due to the hospital not undertaking thorough and appropriate checks to ensure their needs were being met. The avoidable death of any patient is one too many and something that everyone working in the health and care system must do all they can to prevent.

“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 receive safe care and treatment.”

For enquiries about this press release please email regional.engagement@cqc.org.uk.

Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the press office is unable to advise members of the public on health or social care matters.)

Notes to editors

CQC brought this prosecution under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regulation 12 covers healthcare providers’ responsibilities to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.

Regulation 22 made it a criminal offence to not comply with regulation 12.

It is a defence to establish, on the balance of probabilities, that all reasonable steps were taken to ensure safe care and treatment was provided.

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.