Lincolnshire Trust Fined After Patient Suffered Serious Avoidable Harm

Priscilla Lynch 

April 02, 2022

United Lincolnshire Hospitals NHS Trust has been ordered to pay a total of £111,204 in fines and legal costs after pleading guilty to failing to provide safe care and treatment to an elderly patient, causing them avoidable harm, following a sentencing hearing on Friday, 25 March at Boston Magistrates’ Court.

The case was taken by the Care Quality Commission (CQC) under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Avoidable Harm

The case against  United Lincolnshire Hospitals NHS Trust involved the care of an elderly patient, Iris Longmate who was admitted to the Greetwell Ward at Lincoln County Hospital on 20 February 2019.

On March 3, 2019 Iris fainted and fell unsupervised from a commode, and was found face down on the floor in her room. Iris sustained spinal injuries and a cut to the head as a result of the fall, but then also suffered significant burns to her thigh and left arm as a result of being pressed against a radiator whilst being assessed by staff following the fall.

Iris was subsequently transferred to Queens Medical Centre for assessment and treatment. She sadly contracted pneumonia in hospital and died on March 14, 2019.

Findings of the CQC

United Lincolnshire Hospitals NHS Trust pleaded guilty to a single offence of failure to provide safe care and treatment causing avoidable harm to Iris, for which the trust was fined £100,000. The court also ordered the trust to pay £170 victim surcharge and £11,034 costs to the CQC.

The trust was found to not have taken all reasonable steps to ensure that safe care and treatment was provided, resulting in avoidable harm to Iris. In pleading guilty to the offence of causing avoidable harm to Iris, the trust also acknowledged that other patients on the Greetwell Ward had also been exposed to a significant risk of avoidable harm.

Fiona Allinson, CQC’s deputy chief inspector of hospitals, said: "This death is a tragedy. My thoughts are with the family and others grieving for their loss.

"People have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by United Lincolnshire Hospitals NHS Trust," she said. "Had the trust addressed the issues with the exposed heating pipes before Iris fell, she wouldn’t have suffered such awful burns injuries.

"The vast majority of people receive good care when they attend hospital, but if we find a provider has put people in its care at risk of harm, we take action to hold it to account and protect people.

"I hope this prosecution reminds health and social care organisations they must provide care in a safe environment that meets the needs of patients, so they receive the safe care and treatment they deserve."

Background of Cases Filed by the CQC

Since April 2015, the CQC has had the power to bring criminal prosecutions against health and social care providers for failing to provide care and treatment in a safe way.  The CQC has now taken a number of prosecutions against acute hospital trusts, as well as mental health trusts, for care failures under the legislation.

In the first prosecution of its kind, in September 2020, University Hospitals Plymouth NHS Trust was ordered to pay a total of £12,565 after admitting it failed to disclose details relating to a surgical procedure or apologise, following the death of a 91-year-old woman.

The CQC brought the duty of candour prosecution after it emerged that the trust failed to share details of what happened to Elsie Woodfield prior to her death at Derriford Hospital in Plymouth, following an unsuccessful endoscopy procedure. The trust also failed to apologise to Mrs Woodfield’s family within a reasonable timeframe.

In another case in June 2021, East Kent Hospitals University NHS Foundation Trust was ordered to pay a total of £761,170 after admitting it failed to provide safe care and treatment resulting in avoidable harm to two patients in its care, Sarah Richford and Harry Richford.

The CQC brought the prosecution after it emerged that after going into labour a series of events took place which placed Sarah Richford and her baby son Harry, at risk of avoidable harm. Due to the trust not managing this risk of avoidable harm, Harry was born unwell and placed into incubated care on a ventilator. However, as previously reported, 7 days after his birth, Harry died.

In November 2021, the Dudley Group NHS Foundation Trust was fined more than £2.5 million over safety failings after an inquiry into the deaths of two separate patients from sepsis after being "exposed to significant risk of avoidable harm” in Russells Hall Hospital, Dudley, in 2018.

Two of the CQC’s three prosecutions of NHS mental health trusts have been against Southern Health NHS Foundation Trust (October 2017) and Avon & Wiltshire Mental Health Partnership (August 2019), where in each case a patient sustained serious injuries after falling from a roof. The trusts were fined £125,00 and £80,000, respectively.

In 2019, Sussex Partnership NHS Foundation Trust was fined £200,000 after a patient in Lewes prison, who was known as a suicide risk, took their own life.

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