Patient’s death leads hospital to change rules

A PATIENT at Hinchingbrooke Hospital had his chest cavity filled with liquid food after a tube, intended to feed him, was incorrectly inserted, an inquest heard last week. The feeding tube inserted into 76-year-old Peter Cameron s nose failed to reach his

A PATIENT at Hinchingbrooke Hospital had his chest cavity filled with liquid food after a tube, intended to feed him, was incorrectly inserted, an inquest heard last week.

The feeding tube inserted into 76-year-old Peter Cameron's nose failed to reach his stomach and instead directed two litres of liquid food through his right lung into his chest cavity.

Dr Martin Goddard, who carried out the post mortem examination, told the coroner's court last Thursday it was probable that the incorrect insertion of the tube caused Mr Cameron's death.

His wife, Heather Cameron, said in a statement that her husband's death had "devastated his family and undermined their confidence in the quality of NHS care at Hinchingbrooke".

Nine of the hospital's medical staff were at Cambridge Coroner's Court to give

evidence.

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The coroner, David Morris, was told that a test to check if the tube was in the correct position had been carried out and was positive. However, it was said that when Mr Cameron's condition worsened, a senior doctor did not spot that the tip of the tube was in the wrong position.

In addition, the court was told Mr Cameron's patient management plan, which detailed his care, was not followed and his family were not informed about the gravity of the situation.

Mr Cameron, of Old Weston, died on Monday, June 26, this year in Oak Ward.

He had been in and out of hospital with respiratory problems since April, but otherwise doctors said his health was as good as it had been for some time.

It had been decided to feed Mr Cameron with a tube as he was sometimes unable to feed himself.

A naso-gastric tube - which runs through the nose, down into the stomach - was inserted, but had frequently become dislodged and required reinsertion, the court heard.

Nurse Harold Acedo demonstrated to the court the procedure he used to insert the tube at 2.30pm on Saturday, June 24. However, he said he did not check it was in the right position before he finished work for the day about 20 minutes later.

Six hours later another nurse, deputy ward manager Jill Moody, checked the tube's position. She carried out the necessary tests and obtained a pH value of 3.0 - this isan acid reading that should have indicated that the tube was in Mr Cameron's stomach.

Feeding commenced on Saturday evening.

By Sunday Mr Cameron, whose son Jonathan was in court, was said to be in severe pain. The on-call junior doctor ordered an x-ray which was examined by consultant physician Dr Phil Roberts.

He told the court he had "a quick look" at the x-ray but did not see the misplaced tube.

Dr Roberts said he was unaware the tube had been in place and therefore did not look for it. Instead, he said, he focused on the right side of Mr Cameron's chest where there were respiratory problems.

The consultant added that, by the time he had seen the x-ray, "it was probably too late".

Mrs Cameron said she spent Sunday evening and night with her husband. She added he was in severe pain prior to his death the following morning.

Since Mr Cameron's death, Hinchingbrooke has changed its practices, the court was told.

Dr Colin Borland, consultant physician, said the tragic case had led to a review of procedures at the hospital and patients are now routinely x-rayed when naso-gastric tubes are inserted.

The hospital is also training radiographers to identify if a tube is in the correct position.

Coroner David Morris said that he expected to record a narrative verdict on the case next month at a date and venue yet to be confirmed.

Hinchingbrooke statement

The trust would like to offer sincere condolences to Mrs Cameron and the rest of her family.

Mr Cameron's death has been fully investigated by the trust and there have been lessons learned from this unfortunate case.

The staff involved in caring for Mr Cameron did follow the local and national guidelines for the placement and placement testing of the naso-gastric tubes. However, the method used to check the placement of the tube failed to detect that the tube was incorrectly placed.

A National Patient Survey Agency (NPSA) alert issued in 2005 accepts that there is a small risk of this occurring. The NPSA has commissioned the University of Birmingham's patient safety research group to further assess the existing

testing methods, and further guidance is expected in

December. The trust has already supplied a full response to the complaint made by the family and has also offered to meet with family members. The trust will continue to communicate with the family to address any outstanding

concerns following the

inquest.

Nasogastric tube feeding

# Naso-gastric tubes can be used to feed patients who are either unable to feed themselves or need extra nutrition.

# The length of tube required is measured by the nurse performing the insertion. Measurements are taken from the tip of the nose to the earlobe and down to the

stomach.

# The correct positioning of the tube is confirmed either by taking a pH reading or x-ray.

# Readings of less than pH 5.0 are assumed to be correctly positioned as this level would indicate the presence of stomach acid.

# Figures from the National Patient Agency show a total of 11 deaths across the country from incorrectly inserted nasogastric tubes between 2002 and 2004.

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