Case report: Think before you sleep
Mr S was a 70-year-old librarian who had a long history of recurrent colitis due to Crohn’s disease. Despite maximal medical treatment, he experienced recurring symptoms of severe abdominal pain and rectal bleeding, so was admitted to hospital.
Following a period of parenteral steroid therapy, Mr S’s bleeding continued and he required an exploratory laparotomy. Prior to surgery a barium enema revealed a discrete area of abnormal bowel, which was felt to be responsible for his symptoms. It was hoped that the inflamed section of bowel could be surgically resected to alleviate the problems.
Mr S underwent a pre-op assessment by senior anaesthetic trainee, Dr P. He was noted to have a history of angina and COPD, but these chronic conditions were stable.
Dr P had performed this procedure many times before and felt confident to do it independently
On the day of Mr S’s surgery, the operation took place without complication and Dr P inserted an NG tube. As Mr S was intubated, Dr P used a laryngoscope and Magill’s forceps to insert the NG tube. Dr P had performed this procedure many times before and felt confident to do it independently.
During the insertion, Dr P found it difficult to visualise the proximal end of the oesophagus, but based on the smooth insertion assumed the NG tube was in place. Satisfied with the procedure, he escorted Mr S to ICU to begin his recovery.
On arrival in ICU, Dr P still needed to confirm the position of the NG tube. Unable to aspirate fluid, he wanted to auscultate the stomach while instilling air through the NG tube (the ‘whoosh’ or ‘blow’ test) – this was in line with the local protocols at the time. As Mr S had had a laparotomy, Dr P was unable to access the epigastrium to carry out this manoeuvre due to a large wound pad covering the area.
Due to a backlog in the radiology department, the x-ray was not carried out before the end of Dr P’s shift
Dr P decided to arrange a chest x-ray to confirm the position of the NG tube. Due to a backlog in the radiology department, the x-ray was not carried out before the end of Dr P’s shift. Dr P handed over the task of reviewing the film to the nightshift trainee, Dr A. Unfortunately, Dr P failed to inform Dr A that the x-ray was to check the position of the NG tube. Dr P had been so rushed that he had not documented the insertion of the NG tube, or that the correct position had yet to be confirmed.
Following the handover, Dr A noticed there was a leak from Mr S’s endotracheal tube and she injected approximately 1ml of air into the tube’s cuff, which resolved the leak.
Dr A was called away to an emergency, but instructed one of the nurses to observe Mr S. The results of Mr S’s chest x-ray arrived, but Dr A was too busy to review it immediately. When Dr A did look at the x-ray, she glanced at it quickly, verbally informing the nurses that it “looked ok”, referring to the ET position as “satisfactory” and the lungs looking “grossly normal”. She did not document this in the medical notes.
Dr P had been so rushed that he had not documented the insertion of the NG tube, or that the correct position had yet to be confirmed
Unfortunately, Mr S had to return to theatre for an anastomotic leak repair and subsequently required prolonged intubation, blood transfusions, IV fluids and inotropic support after the second surgery. With treatment Mr S’s haemodynamic parameters stabilised although he began to develop renal failure.
On-call consultant anaesthetist Dr W took the decision to begin feeding. During this time, the original NG tube remained in-situ. No-one realised the initial chest x-ray had not been formally reviewed.
When Dr A did look at the x-ray, she glanced at it quickly, verbally informing the nurses that it “looked ok”, referring to the ET position as “satisfactory” and the lungs looking “grossly normal”. She did not document this in the medical notes
About 12 hours later, Mr S’s nurse aspirated feed-like material from his ET tube and feeding was immediately stopped. Dr A was asked to review the patient immediately and while the review was being completed, radiology phoned to advise that the chest x-ray taken before the weekend showed the NG tube was positioned incorrectly.
Despite aggressive treatment for aspiration pneumonitis, unfortunately Mr S’s condition worsened and he died two days later.
The postmortem outlined the cause of death as aspiration pneumonia due to a misplaced nasogastric tube in right main bronchus, left hemicolectomy for intestinal haemorrhage, ischemic heart disease and chronic obstructive airways disease.
Initially, Dr P and the nurses involved were arrested on suspicion of manslaughter and interviewed by the police under caution. However, following an investigation including the obtaining of expert opinion that agreed that the level of care, although suboptimal, did not meet the necessary criteria for a criminal offence, lead to the police deciding that there was insufficient evidence to proceed with the prosecution – the charges were dropped.
The Crown Prosecution Service’s expert opined that the responsibility fell to the practitioner placing the NG tube to check its position. If this is not possible, that practitioner should leave clear written instructions on who will check it.
Two years later, the practitioners involved were called to an inquest and MPS arranged legal representation for Dr P. At the inquest, Dr P accepted that it was an omission on his part not to have specifically recorded in the notes the NG tube insertion.
The coroner recorded a narrative verdict, concluding that Mr S died of aspiration pneumonia due to the incorrect positioning of an NG tube. She criticised all the practitioners involved for failing to detect this.
[The coroner] was satisfied that systems had been implemented by the trust to prevent such an incident recurring
Given that the expert felt that the standard of care was acceptable, however, she took no further action, as she was satisfied that systems had been implemented by the trust to prevent such an incident recurring.
Mr S’s wife launched a claim against the hospital. This was settled for a moderate sum.