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Shrewsbury and Telford NHS Trust admit failures after two patients die


Shrewsbury and Telford NHS Trust admit failures after two patients die

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source of images, Ismael Zaman / Instagram
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Ismael Zaman died of a hemorrhage while receiving dialysis

A hospital trust has been fined more than £1.3million after admitting failures in care that contributed to the deaths of two patients.

Mohammed Ismael Zaman, 31, died of severe blood loss while undergoing dialysis at the Royal Shrewsbury Hospital in 2019.

Max Dingle, 83, died after his head got stuck between a mattress and a bed rail at the same hospital.

His son said the death had been a “total shock”.

Shrewsbury and Telford Hospital NHS Trust (SaTH) has admitted three counts of failing to provide treatment and care in a safe manner, resulting in harm or loss, between October 2019 and May 2020.

He was fined £800,000 for the death of Mr Zaman, known as Bolly, and £533,334 for the death of Mr Dingle.

Charges have been brought against the trust by the Care Quality Commission (CQC) under the Health and Social Care Act 2008.

Shrewsbury and Telford NHS Trust admit failures after two patients diesource of images, Family document
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Max Dingle died after his head and neck were trapped between a mattress and bed rails

Representing the CQC, Ryan Donoghue said the failures in Mr Zaman’s care “were the legal cause of his death, for which the trust is responsible”.

Mr. Zaman was receiving treatment on October 18, 2019 when his catheter, which entered his jugular vein, came out. An alarm went off, but it was not checked before staff turned it off.

By the time staff noticed what had happened, he had lost half of his blood supply.

Mr Dingle, a retired police officer from Newtown, Powys, mid Wales, had been admitted with a chronic lung condition in April 2020, the court heard.

Heart attack

He was overweight so was placed in a larger bariatric bed and staff were not trained in its use.

On May 3, he was found with his feet on the ground, his head and neck trapped. He was purple, his eyes bulging, and he died of cardiac arrest after being released.

Phil Dingle has criticized the trust’s response to his father’s death, accusing them of trying to “whitewash” the circumstances.

He remembered his father as “a mountain of man” who was always the source of good advice.

” The base [of the guilty plea] is that the failures put him at significant risk of avoidable harm,” Donoghue said.

Shrewsbury and Telford NHS Trust admit failures after two patients diesource of images, Ismael Zaman / Instagram
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The CQC said staff did not follow guidelines for dialysis connection lines

In addition to the two deaths, the CQC accused the trust of putting other patients at significant risk of preventable harm.

In court, SaTH acknowledged that it would take considerable time to rebuild trust with the local community after pleading guilty.

The trust’s lawyer said the deaths were “tragedies” and offered his heartfelt condolences to the families.

“Unimaginable grief”

The trust is currently £60m in debt and at the hearing Senior District Judge Paul Goldspring acknowledged that every pound he imposed on the trust would be ‘a pound that does not go to patient care’ .

“It’s a diabolical, deep blue exercise,” he said. “At the end of the day, fines hurt patients. »

However, the patients’ families had suffered “unimaginable grief”, he concluded, adding that the breaches were compounded by a fine imposed by SaTH in 2016 for a poor health and safety record in running the facility. Royal Shrewsbury Hospital.

In mitigation, Judge Goldspring said the trust conducted “full and thorough investigations immediately following both incidents.”

Shrewsbury and Telford NHS Trust admit failures after two patients diesource of images, Getty Images
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Shrewsbury and Telford Hospital NHS Trust has also come under heavy criticism over maternity failures

The CQC said Mr Zaman and Mr Dingle had been “seriously disappointed” with the trust.

“People using health and social services have a right to safe care and treatment, so it is unacceptable that patient safety has not been well managed by the Shrewsbury and Telford Hospital NHS Trust,” said Fiona Allinson, of the watchdog.

Following the hearing, SaTH released a statement in which its Director of Nursing Hayley Flavell said: “We are truly sorry for the pain and distress caused by the failures in the delivery of care.

“We extend our sincere apologies and heartfelt condolences to the families we left behind,” she said, adding a pledge to improve care at the trust.

The trust recently faced a damning review of its maternity services.

The Ockenden review, published in March, found that “repeated errors in care” within the trust contributed to the deaths of 201 babies between 2000 and 2019.

Shrewsbury and Telford NHS Trust admit failures after two patients die

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