Hospital cleared over pensioner's death
Susanna Wilkey A West Hampstead pensioner who had a stomach tube twice inserted into his lungs died of natural causes, an inquest has ruled. The accidental treatment contributed but did not directly cause 86-year-old Wilfred Rowley s death at the Royal Fr
A West Hampstead pensioner who had a stomach tube twice inserted into his lungs died of natural causes, an inquest has ruled.
The accidental treatment contributed but did not directly cause 86-year-old Wilfred Rowley's death at the Royal Free Hospital in Hampstead, recorded Coroner Andrew Reid.
Stricter assessment and training days have now been introduced at the hospital in response to the accident which happened last August.
Specialist in nutritional support, Nurse Jose Bennell, told St Pancras Coroner's Court: "Inserting a naso-gastric tube is invariably risky and not 100 per cent safe.
"We need to make sure our guidelines are clear but we need to be honest with the patients and ourselves that it is risky when we decide to artificially feed a patient.
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"The guidelines do not require chest x-rays as a matter of course.
"I am confident the nurses followed the guidelines in this case and in neither case do I get any concern about the level of practice or skill.
"We are currently investigating in conjunction with the Patient Safety Commission and we will be ensuring from now on that all nurses are consistently assessed for the insertion of nasogastric tubes.
"At the Royal Free, we have training days and the nasogastric tube has been included in that."
Retired factory worker Mr Rowley, of Kylemore Road, West Hampstead, was admitted to the hospital after suffering a stroke. He was having trouble breathing and swallowing.
On August 19, it was decided he needed a nasogastric tube. The tube is inserted through the nose into the stomach so the patient can be artificially fed.
But the tube was inserted into his right lung and penetrated his pleura.
Nurses noticed he had difficulty breathing and, despite his pH levels indicating that the tube was in the stomach, sent him for a chest x-ray which showed the error.
Another tube was inserted by a different nurse the next day which went into his left lung and was again removed after a chest x-ray.
Mr Rowley was given a chest drain but his condition continued to deteriorate and he died on August 22.
Dr Sheldon Stone said: "There is no evidence that food was given down the tubes at any time.
"I think the nursing team did very well because they followed their clinical instinct and waited for an x-ray before giving him any food.
"Things could have been a lot worse for this man if they had not done that."
Dr Reid said: "I am satisfied that steps have been taken to look at this issue and lessons that can be learned from it and training and education is being rolled out to nurses involved in nasogastric tube insertion.
"These steps will serve to prevent similar complications in the future.