TWO patients suffering from sepsis died at Dudley's Russells Hall Hospital after inspectors’ warnings about failings in care were not acted upon, a court has heard.

Wolverhampton Magistrates’ Court was told the Care Quality Commission (CQC) informed the Dudley Group NHS Foundation Trust that its staff were not clear on how to follow a sepsis treatment “pathway” in the months leading up to both deaths.

The trust pleaded guilty at a previous hearing to safety failings posing a “significant risk of avoidable harm” following the deaths of mother-of-six Natalie Billingham, aged 33, and 14-year-old Kaysie-Jane Robinson in March 2018.

A lawyer acting for the Dudley Group NHS Foundation Trust admitted two breaches of the 2008 Health and Social Care Act on the trust’s behalf in July after an investigation by the CQC.

The charges admitted by the trust stated it had failed to provide treatment in a safe way, resulting in harm, in February and March 2018.

Opening the facts of the case on Thursday, the CQC’s barrister, Ian Bridge, said Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on February 28, 2018, and died on March 2 of organ failure caused by a “time critical” infection.

The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify “disordered” observations.

The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were “missed or ignored”.

In the case of Kaysie-Jane, who had cerebral palsy, an “early warning score” was inaccurate, meaning a sepsis screening tool was not triggered.

The court heard the teenager, who died six days later after being transferred to another hospital, was initially believed to have gastroenteritis.

Mr Bridge, who described sepsis as a “stealthy and vicious” condition, added: “In the months leading up to these two tragic cases, the Russells Hall Hospital had been the subject of a series of unannounced inspection visits by the Care Quality Commission.”

Unacceptably poor standards of care and treatment had been identified, Mr Bridge said, which were directly related to the “failings which were present in both of these cases”.

Mr Bridge added: “The visits are documented at length in the witness statements.

“The statements also document correspondence and action taken in consequence of their findings.”

Concerns in relation to sepsis management and patient monitoring had been raised during the inspections, the court heard.

Mr Bridge added that a letter sent by the CQC had informed the trust that “staff were not clear on how to follow the sepsis pathway”.

The failures, the CQC’s counsel said, were brought to the attention of the trust “in a rapid fashion” but they were not acted upon.

The trust is due to be sentenced on Friday.

It said in a statement issued last summer that it was “deeply sorry” that its care did not meet the high standards Kaysie-Jane and Natalie and their families had a right to expect, and “did not reflect the values of our trust”.