Man died in Exeter hospital after tube was wrongly inserted into his lung

A liver transplant patient died after a hospital ‘never event’ in which a nasal gastric feeding tube was wrongly inserted into his lung.

Retired civil engineer Charles Ward died at the Royal Devon and Exeter Hospital two days after the nasogastric tube was fitted in January 2012.

Staff nurse Gavin Kelly who misplaced the tube told an Exeter inquest yesterday:”I had no reason to believe it was in the wrong place at the time.”

He said 62 year old Mr Ward ‘coughed and spluttered’ when the tube was inserted and the nurse said:”It is not a pleasant procedure.”

Mr Ward, of Dawlish Warren, Devon, had been fed for six hours by the tube when he collapsed in his bed at 4am.

A crash team was called and he was taken into intensive care where he died a day later.

The Devon coroner Dr Elizabeth Earland was told that since Mr Ward’s death, procedures had been changed at the hospital.

A second nurse, Paul Jenkins, told the inquest that Mr Ward had slumped on his bed on his side and was fighting for breath.

He said when the tube was inserted, Mr Ward ‘coughed and spluttered several times’ as he tried to get his breath back.

He added that Mr Ward had been ‘a bit agitated’ but there ‘was no mention of the tube being in the wrong place’.

Nurse Jenkins said Okement ward at the hospital was ‘always busy’ and staff had been dealing with a couple of falls and some confused patients but he said ‘we were not rushed off our feet’.

A medical expert Dr Jason Payne-James, a consultant forensic physician, said:”I do not believe these actions constitute gross negligence.”

But the coroner heard that the feed tube used on Mr Ward was withdrawn after his death and a new model is used which a tip which is easier to see on an X ray.

Solicitor Julie Ford, for the hospital Trust said the incident was ‘an unintended consequence of an intended action’.

The coroner recorded a narrative verdict and said Mr Ward died from chemical pneumonitis caused by the liquid feed going into his lung because of the naso gastric tube being wrongly positioned.

An acid PH test was carried out incorrectly by the staff nurse which should have indicated the tube had been inserted into Mr Ward’s lung and not his stomach.

The inquest was told he suffered liver disease and was awaiting a liver transplant but he needed feeding up to make him fit enough for the surgery.

A spokesman from the hospital said:”The Trust has been in contact with Mr Ward’s family from the outset of our investigation into this incident to provide as much support and information as possible.

“The Trust takes any incident of this nature – known as a Never Event - extremely seriously and although they are very rare, they are acted on immediately, fully investigated and lessons identified so that the risks of them happening in future are minimised.”

Em Wilkinson-Brice, Chief Nurse and Chief Operating Officer at the RD&E, said: “Providing safe care to patients is our top priority and our clinical teams work to exceptionally high standards. It is important that staff feel comfortable in reporting any incidents and that we learn from them.”

This article is courtesy from Exeter Express and Echo.