Shrewsbury and Telford NHS Trust admits failures after two patients die

Ismael Zaman bled to death while receiving dialysis

A hospital trust has been fined more than £1.3m 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 became trapped between a mattress and bed rail at the same hospital.

His son said the death had come as a "total shock".

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

It was fined £800,000 relating to the death of Mr Zaman, known as Bolly, and £533,334 for Mr Dingle's death.

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

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 18 October 2019 when his catheter, which went into his jugular vein, came out. An alarm went off, but he was not checked before staff switched it off.

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

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

Cardiac arrest

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

On 3 May he was found with his feet on the floor and with his head and neck trapped. He was purple, his eyes were bulging and he died from a cardiac arrest after being freed.

Phil Dingle criticised 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 a man" who was always the source of great advice.

"The basis [of the guilty plea] is that the failures exposed him to a significant risk of avoidable harm," Mr Donoghue said.

The CQC said staff had not followed guidelines around dialysis connection lines

As well as the two deaths, the CQC accused the trust of exposing other patients to significant risk of avoidable harm.

In court, SaTH accepted it would take considerable time to rebuild trust with the local community after entering guilty pleas.

The trust's barrister said the deaths were "tragedies" and offered sincere sympathies to the families.

'Unimaginable grief'

The trust is currently £60m in debt and during the hearing Senior District Judge Paul Goldspring acknowledged every pound he fined the trust would be "a pound that doesn't go on patient care".

"It's a devil and deep blue sea exercise," he said. "In the end, fines make patients suffer."

However, the families of the patients had suffered "unimaginable grief", he concluded, adding the offences were aggravated by a 2016 fine SaTH received for a poor health and safety record in the management of the Royal Shrewsbury Hospital.

In mitigation, Judge Goldspring said the trust had carried out "full and extensive investigations immediately after both incidents".

Shrewsbury and Telford Hospital NHS Trust has also faced intense criticism over maternity failings

The CQC said Mr Zaman and Mr Dingle had been "severely let down" by the trust.

"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," Fiona Allinson, from the watchdog, said.

Following the hearing, SaTH issued a statement in which its director of nursing Hayley Flavell said: "We are truly sorry for the pain and distress caused as a result of the failures in the provision of care.

"We offer our sincere apologies and heartfelt condolences to the families we let down," she said, adding a commitment to improve care at the trust.

The trust was recently subject of a damning review into its maternity services.

The Ockenden review, published in March, found "repeated errors in care" at the trust contributed to the deaths of 201 babies between 2000-2019.