A Norfolk hospital trust has been fined £60,000 after pleading guilty to failing to provide safe care and treatment, which exposed a patient to significant risk of avoidable harm.
The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust was sentenced today (Thursday 8 December) at Chelmsford Magistrates’ Court.
The criminal offence, prosecuted by the Care Quality Commission (CQC), stems from the trust’s failure to safely manage scan reports.
Lucas Allard, who had a complex medical history and was awaiting heart surgery, attended the trust’s emergency department on 12 March 2019 with chest pain.
Staff arranged for the 28-year-old to have a computerised tomography (CT) scan.
After initial difficulty locating his scan report, staff assessed what was thought to be Mr Allard’s result. This indicated he was fit for discharge.
A review by a consultant two days later found the wrong report had been viewed. The correct report showed significant abnormality.
Mr Allard was then urgently called to the hospital.
Shortly after arriving, Mr Allard suffered a cardiac arrest. Although staff attempted resuscitation, they were unable to save his life.
Zoe Robinson, CQC head of hospital inspection, said:
“Lucas Allard had the right to expect safe care and treatment from the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, so the trust’s failure to ensure its staff reviewed correct scan results is unacceptable.
“If the trust had identified and addressed the weakness of its system, it could have appropriately responded to Mr Allard’s condition and provided him with the urgent care he needed at the earliest opportunity.
“The vast majority of people receive good care when they attend hospital. However, when a healthcare provider puts people in its care at risk of harm, we take action to hold it to account and protect people.
“I hope this prosecution reminds healthcare providers of their legal duty to always take all reasonable steps to ensure people’s safety.”
Regulated health and social care providers have a specific legal duty to ensure their patients receive safe care and treatment, with risks to people’s health and wellbeing being appropriately managed.
The trust has admitted it had not ensured safe care and treatment due to its lack of adequate processes and systems to ensure staff reviewed correct scan results, and to ensure results showing abnormalities were appropriately escalated.
Behind this was the trust’s failure to ensure the provider of its out-of-hours radiology service issued a verbal report when a scan identified abnormalities. This situation was worsened because the trust’s computer system for managing scan results was outdated and incompatible with systems used by its out-of-hours radiology provider.
The trust has also admitted these failures exposed Mr Allard to a significant risk of avoidable harm.
This constitutes a breach of regulations 12 and 22 (2) (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Regulation 12 relates to healthcare providers’ responsibility to ensure people receive safe care and treatment. Regulation 22 made it a criminal offence to not comply with regulation 12.
In addition to the fine imposed by the court, the trust has been ordered to pay a £170 victim surcharge and £4,500 costs to CQC.