A “dearly loved” retired fireman died in hospital after a feeding tube was mistakenly inserted into his lungs, which was missed by a junior doctor, an inquest heard.
Great-grandfather Terry Butler, 83, was admitted to the Royal Albert Edward Infirmary in Wigan with an infection in December last year and brain scans showed he had suffered a minor stroke. When he had trouble eating and drinking a feeding tube known as a nasogastric tube was inserted in his nose but accidentally went into his lung, rather than his stomach.
An x-ray was taken to check it was in the right place but the image was “inaccurately interpreted” by a junior doctor, who had had no training in checking the procedure, Bolton Coroner’s Court was told. As a result, 150 to 200 millilitres of fluid was pumped into Mr Butler’s lungs over a 15-minute period, before he began to develop chest pains and he died a month later.
The junior doctor missed the feeding tube in Mr Butler's lung (Adam Vaughan)Elizabeth Harrison, his daughter, told the inquest: “We were told terrible news, dad only had a fifty-fifty chance of survival. He was very much loved by all his family and those who knew him. He is very sadly missed. The family are struggling to come to terms with his death. We feel he could have gone on to live for a few more years. We feel dad unduly suffered.”
Coroner Alexander Frodsham, assistant coroner for Manchester West, was told the incident was a “never event” which should not have happened. Nicola Heath, head of governance at the hospital, said an investigation was held and she had spoken to the junior doctor involved. She said the investigation identified the doctor involved had not been trained to confirm the correct placement of a nasogastric tube, was not aware training was available and had wrongly interpreted the X-ray images. She could not say if he was disciplined.
Brit 'saw her insides' after being cut open by propeller on luxury diving trip
The inquest heard there were two similar incidents involving nasogastric tubes at the hospital – in 2017, when the doctor who interpreted the X-ray had not been trained, and in 2019, when the doctor interpreted the image in error. After the 2017 incident, nasogastric tube placement training became mandatory for junior doctors, but the doctor in Mr Butler’s case, “slipped through the net”.
Stephen Jones, representing the Butler family, said this was a “gross failure”, adding: “This doctor should have been trained and wasn’t.”
Coroner Alexander Frodsham concluded Mr Butler died as a result of misadventure contributed to by neglect. After the inquest, the Butler family said in a statement: “As a family we are devastated at his loss. We feel it was not Dad’s time to die and had it not been for this incident he would now be at home enjoying life with his family. We have some wonderful memories of Dad and he will always be in our hearts.”
Professor Sanjay Arya, medical director at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, said: “We extend our deepest sympathies and condolences to Mr Butler’s family and friends. We always try to do our best for our patients but on this occasion, standards of care were not met, as a result of which we failed the patient and the family, for which we are truly sorry.
“Following this incident, a thorough investigation was conducted and reviewed, and a comprehensive action plan was implemented. We also acknowledge the need for continuous improvement and are fully committed to learning from every aspect of the care provided. The Trust remains dedicated to delivering the highest standard of care and the safety and well-being of our patients will always be our top priority.”
Read more similar news:
Comments:
comments powered by Disqus
