“It was a wholly avoidable and tragic death of a vulnerable patient admitted to hospital for care but who died because of a lack of it”.. so said Mr Justice Haddon-Cave while pronouncing the verdict on the case of Gillian Astbury. If you don’t know that name by now, then throw away all the leaflets you have collected about “safe patient care”, the courses you have attended learning about the 6 Cs or even joyfully pledging to be part of NHS Change Day. Because if you don’t know that name then all of what you have done are gimmicks and you have learnt nothing.
Gillian Astbury, was a 66 year old lady who dies in 2007 in Mid Staffordshire hospital because of not being given her insulin. She was the lady whose case Francis reviewed and criticised the Health and Safety Executive, whose case finally provoked the HSE to bring criminal prosecution against the Trust- which concluded with the judgement as above associated with a fine of £200,000. I won’t go through the details of what the Francis report said but it cannot get any more damning. To all those who say Mid Staffs was over-reported, I say read this case and then suggest have a humble moment- and then reflect how different it is to Mel Gibson’s drunken rants about the Holocaust.
But you know what’s astonishing? Even today 7 years later, even after the Francis report, these occurrences are regular. Ask any diabetes team inside a hospital; ask patients who are afraid to go to the hospital…reason? Diabetes still continues to be an ignored pathology within hospital trusts. Look at the National Inpatient audit results..and the results are stark. Evidently education will solve all- I can absolutely assure you it doesn’t-sadly.
Most hospitals still run a 5 day service- with patients openly saying their worry about going to hospitals on weekends, we still dither, we still stall. As a specialist, it has made me angry in the past- but reading that news made me pledge never to brook any resistance to what must be done. Is it my role to appease others or to pledge to Gillian’s family that we have learnt and we now will treat patients with diabetes with the respect they deserve? Today, publicly, I choose the latter and lucky to have local Commissioners and Trust senior executives who support this- so no more obstacles, no more meetings, this now must happen. Patients with diabetes don’t choose a 5 day service and neither should we deliver one
Finally a word to all the so called diabetes professional organisations. Sometimes it’s a good thing to simply say sorry, take responsibility for our lack of passion as specialists that we haven’t been able to show the leadership needed to fight the battle for patients with diabetes. I have yet to see a single statement from the specialist diabetes body ABCD, Diabetes UK..in fact anyone acknowledging this horrible error which we must not let happen again, saying something on the day when the judgment was pronounced, something which shows a williingness to learn and make amends.
So you know what? I don’t stand for any organisation but to Gillian’s family- I say sorry. I swear I will do anything within my powers to make sure this doesn’t happen where I work. And if you want to stand in the way of that, stand in the way of what patients need to avoid another Gillian Astbury, then I am afraid your role in whatever capacity in a healthcare setting is defunct.
Lets do what needs to be done, shall we?