A seriously ill man died in hospital from a wrongly-placed feed tube which was found to have gone into a lung instead of his stomach.
Chesterfield coroner’s court heard on Wednesday, April 22, how John Craven, 73, of Cuttholme Road, Chesterfield, died from a perforated lung with pneumonia at Chesterfield Royal Hospital.
Despite a radiographer identifying the naso-gastric-tube had been wrongly positioned in an x-ray, according to the three-day inquest, the tube was still wrongly reported among staff as being in the right place and it was allowed to be used despite discussions and concerns.
Assistant coroner for Derbyshire James Newman said: “There is no evidence before me that the tube was placed anywhere other than in the left lung. It was badly positioned and erroneously reported as being in the right place.”
Mr Newman raised concerns about the lack of documentation, a failure to report difficulties in placing the tube, a failed opportunity to report concerns raised by the radiographer and that further discussions failed to identify the problem.
Consultant Dr Anil Kumar Agarwal, who had no involvement with tube insertion, revealed Mr Craven had been admitted to Chesterfield Royal Hospital on June 21, 2010, and was suffering with heart, kidney and lung problems with pneumonia.
Mr Newman said Mr Craven was assessed as being unsafe to swallow so after a number of attempts a nurse placed the tube for food and medicine and she was told by a radiographer it had gone into the left lung and she urged the nurse to tell a doctor.
The inquest heard how a doctor sought a second opinion and the tube was wrongly recorded as correctly placed.
Mr Craven was suffering with a chest infection and a weak heart and his condition deteriorated and he passed away on July 1, 2010.
Hospital trust Medical Director Dr Gail Collins, who accepted policies had not been followed, said: “We agree with the coroner that whilst Mr Craven was very ill, had it not been for the incident, he would not have died when he did.”
Ms Collins confirmed a member of the nursing staff has been dismissed and improvements have been introduced with new policy, staff information, training, documentation and assessments.
She added Mr Craven’s family indicated they were pleased to hear of the positive changes and a written apology will be sent to them.