Frederick Davidson · Prevention of Future Deaths report

On 28th December 2011 I opened the inquest into the death of Frederick Davidson, who at the date his death was 80 years old. The inquest was resumed and concluded on 23/9/13.
I found that the cause of death to be:

1a – Aspiration pneumonia secondary to recurrent epileptic seizures complicated by misplacement of nasogastric tube
2 – Ischaemic heart disease mixed Alzheimer’s and vascular dementia.

I concluded with a narrative conclusion as follows:
On 9/12/11 Frederick Davidson who had a history of advanced dementia and chronic seizure was admitted to Epsom General Hospital with aspiration pneumonia. It was subsequently discovered that he had developed a pneumothorax as a result of being fed via an unnoticed and incorrectly placed nasogastric tube, which on the balance of probabilities hastened his death on 20/12/11.

Frederick Davidson was admitted to Epsom General Hospital on 9/12/11 upon referral by his consultant doctor, after he was found to have developed aspiration pneumonia. He had suffered two seizures the week before his admission. He was fed via a naso gastric tube which was misplaced and unnotified for 24 hours notwithstanding several chest x rays taken. As a consequence he suffered a pneumothorax but despite treatment he succumbed and died on 20/12/11.

During the inquest ████████ who conducted the SI Report provided very helpful evidence and the following concerns were highlighted: -

• Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology

I would ask that you consider the guidelines on the urgency of x rays and staff training needs when a pneumothorax is suspected and/or concerns raised about the placing of a nasogastric tube.