Margaret Burton, 90, dies after a feeding tube is inserted into her lung
Clinical Negligence News : 30 May 2012
Margaret Burton, a 90-year-old former shop owner died following the incorrect insertion of a feeding tube into her lung instead of her stomach. Mrs Burton suffered complications as a result of the error and subsequently died of pneumonia on March 31st 2009. Mrs Burton was first taken into North Tees Hospital on March 13th 2009 after suffering a serious stroke at her home.
After being admitted to the hospital, doctors realised that she was having difficulties swallowing, and consequently made the decision to insert a feeding tube into her stomach. A nurse was instructed to insert the tube into Mrs Burtons’ stomach but incorrectly inserted it into her left lung. An x-ray was performed immediately after the incorrect insertion but a junior doctor failed to notice that the tube was in the wrong place. Due to this error, more than 300ml of food was passed into Mrs Burtons’ lung overnight.
A second x-ray was performed the following day and it was then that the doctors realised that the feeding tube had been inserted into her lung causing irreversible damage. The tube was immediately removed but Mrs Burtons’ condition continued to deteriorate and she died on March 31st 2009 after contracting pneumonia.
An inquest into the death of Mrs Burton recorded a verdict of accidental death, contributed to by system neglect. The Coroner stated, "The University of North Tees Hospital failed to have a system to check whether the doctors concerned had the appropriate competency in interpreting the placement of naso-gastric tubes by x-ray. Also at that time, the hospital did not provide to the relevant doctors formal training on x-ray interpretation on the placement of naso-gastric tubes."
Following the tragic circumstances surrounding Mrs Burtons’ death, the hospital’s Trust has now put in place training for junior doctors to ensure that they are fully capable when it comes to interpreting these kinds of x-rays.