Terence Harry Clark · Prevention of Future Deaths report

On 3rd November 2023 this court commenced an investigation into the death of Terence Harry Clark, aged 76. The investigation concluded at the end of the inquest on 27th August 2024 when the court returned a narrative conclusion.

“Terence Harry Clark died in hospital on 1st November 2023. Mr Clark had numerous co-morbidities including an impaired swallow. On 26th October 2023 he was admitted to hospital by ambulance with aspiration pneumonia. On 1st November 2023 he was fitted with a naso-gastric tube which required radiological confirmation of its siting. Mr Clark sustained a cardiac arrest whilst waiting unescorted in the X-ray waiting area.”

Mr Clarks medical cause of death was determined as;

1a Aspiration Pneumonia
1b Right Frontal Lobe Ischaemic Stroke, Dementia
II Chronic Obstructive Pulmonary Disease, Diabetes Mellitus

Terence Harry Clark was 76-year-old man with considerable co-morbidity, including a compromised swallow, dysphagia.

Mr Clark was admitted to hospital by ambulance on the evening of 26th October 2023 with difficulty in breathing. Mr Clark was diagnosed with bilateral aspiration pneumonia. The deceased was admitted and treated with anti-biotics.

Mr Clark was assessed by the speech and language team who advised that to protect his airway from further aspiration he should be made subject to a nil by mouth order pending the trial of feeding using a naso-gastric (“NG”) tube.

On 1st November 2023 Mr Clark underwent NG tube insertion which required an x-ray to ensure that the tip of the tube was correctly sited in his stomach, and not in an airway. It is reported that prior to an x-ray no feed was introduced via the apparatus.

Against Trust policy, Mr Clark was sent to the imaging suite unescorted by nursing or medical staff. Mr Clark’s x-ray was never completed, passing members of trust staff found Mr Clark, unresponsive in the imaging suite waiting area and alerted their radiology colleagues.

As Mr Clark was unescorted, little was known about the patient. CPR was commenced and subsequently discontinued when it was learned that the patient had a do not attempt cardio-pulmonary resuscitation order in place. Mr Clark was declared deceased.

A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark’s airway at autopsy. The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.

B. The Trust conducted a patient safety investigation into the circumstances leading to Mr Clark’s death, the investigation did not identify the removal of the NG tube as a significant factor worthy of scrutiny. Both of these issues raise a concern that the Trust can not adequately secure and review evidence relevant to governance and coronial investigations, necessary to mitigate risks of future fatalities.