A hospital trust has been fined for failing to be open and transparent with the bereaved family of a 91-year-old woman in the first prosecution of its kind.
Elsie Woodfield died at Derriford hospital in Plymouth after suffering a perforated oesophagus during an endoscopy.
The Care Quality Commission (CQC) took University Hospitals Plymouth NHS trust to court under duty of candour regulations, accusing it of not being open with Woodfield’s family about her death and not apologising in a timely way.
The trust admitted its failings and the district judge Joanna Matson, sitting at Plymouth magistrates court, ordered it to pay £12,565.
Matson was told Woodfield’s daughter Anna Davidson eventually received a letter apologising over her mother’s death, which happened in December 2017, but she felt it lacked remorse.
Davidson said she still had many unanswered questions and found it “impossible to grieve”.
The judge 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 their tragic death, but their loss has been compounded by the trust’s lack of candour.”
Speaking afterwards, Nigel Acheson, the CQC’s 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.
“This is the first time CQC has prosecuted an NHS trust for failure to comply with the regulation concerning duty of candour.”
Lenny Byrne, the trust’s chief nurse, issued a “wholehearted apology” to Woodfield’s family. “We pleaded guilty to failure to comply with the duty of candour and fully accept the court’s decision. We have made significant changes in our processes.”
The trust pleaded guilty to breaching regulation 20 of the Health and Social Care Act 2008 (Regulated Activities), Regulations 2014. The regulation came in the wake of the scandal surrounding the Mid Staffordshire NHS foundation trust, where staff did not feel able to, or feel the need to, inform managers, ministers or patients about adverse incidents.
After the hearing, Davidson said: “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 is 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.”