NHS trust fined for lack of candour with family after patient's death in landmark case

An NHS hospital has pleaded guilty to not being open with the family of a patient who died in the first criminal prosecution of its kind.

University Hospitals Plymouth Trust was fined and ordered to pay legal costs totalling £12,565 after being taken to court by care watchdog the Care Quality Commission.

It was charged with breaching the law on duty of candour which requires NHS hospitals to be honest with patients and families when mistakes in their care happen.

The case was brought over the trust’s handling of the death of Elsie Woodfield, aged 91, at Derriford Hospital after she went in for an endoscopy procedure in December 2017.

Mrs Woodfield suffered a perforated oesophagus during the endoscopy in December 2017. As a result, the procedure was abandoned, and Mrs Woodfield was transferred to the hospital’s Marlborough Ward for observations. While there she collapsed and later died.

The CQC said the trust failed to tell Elsie's family that her death, just hours later, might have been caused by a mistake during the procedure.

It said the trust did not share details of what had happened after the unsuccessful procedure and it failed to apologise to the family within a reasonable timeframe.

Elsie's daughter Anna Davidson claimed a letter apologising for the incident lacked "remorse".

She said: "Our family is very grateful to the CQC for pursuing this prosecution to a successful conclusion. All we have sought from the beginning is openness and honesty from the trust as to what occurred that day. The lack of this has been extremely hurtful and disrespectful and has had a lasting negative emotional impact on us all.

“We hope this conviction will underline to other hospitals the critical importance of advising patients and families as soon as it’s recognised mistakes have occurred and of apologising unreservedly. This will help others in similar circumstances avoid the unnecessary pain, anxiety and stress we have suffered.”

The trust admitted breaching Regulation 20 of the Health and Social Care Act 2008, the duty of candour regulation, which is one of 12 fundamental standards brought in after the Mid Staffordshire hospital care scandal.

The trust failed to communicate with the patient's family about what had happened in an open and transparent manner, the court was told.

Although the trust had a policy in place for dealing with incidents, Mrs Woodfield’s death was not categorised as a serious incident requiring investigation as her death was a known complication of the prodcedure. This was a mistake which meant the trust did not follow its process for duty of candour.

Nigel Acheson, deputy chief inspector of hospitals, said: “All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen.

“Sadly, Mrs Woodfield’s family received neither a prompt apology nor full explanation regarding the tragic events that took place prior to her death. University Hospitals Plymouth NHS Trust was not transparent or open with regards to the surgical error and it did not apologise to Mrs Woodfield’s family in a timely way.

“Patients and their families are entitled to the truth and a formal written apology as soon as is practical after a serious incident, and the University Hospitals Plymouth NHS Trust’s failure to fulfil this duty is why CQC took this action.

“This is the first time CQC has prosecuted an NHS trust for failure to comply with the regulation concerning duty of candour, and we welcome the outcome of today’s hearing.”

Mr Williams, representing the trust, said: "This is a threefold apology, the first is for the incident itself, secondly for the breach, and thirdly for the effect it has had only the family.

"An offer to meet has been made on numerous occasions, but for reasons, it hasn't taken place. Later on, it wasn't appropriate because of an investigation at that stage.

"While we accept there has been a failing with communications from the trust. There were multiple communications going backwards and forwards. What I would like to make clear is there has been a great deal of introspection from the trust, none the less.

"I would not want there to be the view that the trust has not looked clearly at what has happened."

District judge Joanna Matson acknowledged that the trust had entered a guilty plea at the first possible opportunity, and was entitled to credit for doing so.

But, she added that the maximum penalty guidelines weren't sufficient to cover the distress caused to the woman's family – and held the trust accountable for all the legal costs.

She said: "This offence is a very good example of why these regulatory offences are very important.

"Not only have [the family] had to come to terms with the tragic death, but their loss has been compounded by the trust's lack of candour.

"That communication was clearly not sufficient.

"My view is that any fine in that range would be insufficient to deal with the extent of harm and distress that was caused to the family, but I am limited by the law.

"Therefore, I fine the trust £1,600, and there will be a victim surcharge which will be £120."

The legal costs the trust were required to pay totalled £10,845, bringing the total cost to the trust up to £12,565.

Additional reporting by agencies