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Investigation and inquest
On 21/12/2017 I commenced an investigation into the death of Peter John Hussey, aged 81, which concluded at the end of the inquest on 19th April 2021. The deceased was diagnosed with mid rectal cancer in 2016. He underwent anterior resection of the bowel with loop ileostomy on the 7th October 2016. He underwent elective reversal of the ileostomy on the 4th December 2017 at the University Hospital North Midlands. On the evening of the 5th December 2017 nursing staff noted he was vomiting. A nasogastric tube was passed at 03.20 hours on the 6th December 2017 but he continued to vomit despite the nasogastric tube being in place. A chest x-ray confirmed aspiration pneumonia and abdominal film reported an evolving adynamic ileus. He was transferred to the intensive care unit but continued to deteriorate and died at 20.00 hours on the 12th December 2017.
The following probably contributed to his death:-
The use of a nasogastric tube which was unsuitable when used for stomach decompression. A failure to recognise that the nasogastric tube was inadequately draining and to consider alternative methods of treatment and to escalate his deteriorating condition.
The following possibly contributed to the death :-
Miscommunication between Enteral, the manufacturer of the tube, and the Hospital Trust as to the correct usage of the carefeed 14F nasogastric tube.
A failure by the Trust to adequately evaluate the nasogastric tube during the procurement process. The cause of death was
1a. Aspiration pneumonia
1b. Intestinal ileus.
1c. Reversal of ileostomy.-
2. Chronic obstructive pulmonary disease and pulmonary fibrosis combined.
The conclusion of the inquest was: - The deceased died from post-surgical complications which included the use of a carefeed 14F nasogastric tube which inadequately drained the stomach allowing vomiting past the tube leading to aspiration pneumonia and death.
Circumstances of the death
See above
The published report provides this section by reference to another part of the report.
Coroner’s concerns
(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector.
(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change.
(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube. Feedback was generally difficult to obtain.
(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining. There was no general recognition of the need to aspirate the tube.
(5) There is no compulsory training of clinicians required to undertake root cause analysis.
(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see attached link to the Nursing Times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/
(7) This was a joint inquest into the deaths of two patients who died in quick succession as a result of the Enteral 14F nasogastric tubes being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.
