Michael Parke · Prevention of Future Deaths report

On 13th December 2012 I commenced an investigation into the death of Michael Parke aged 40 years. The investigation concluded at the end of the inquest on 16th January 2017. The conclusion of the inquest was:

1. Medical Cause of Death:
1a) Aspiration Pneumonia following a misplaced nasogastric tube for treatment of gastrointestinal haemorrhage due to underlying alcoholic liver disease.

2. How, when and where, and for investigations where section 5(2) of the Coroners and Justices Act 2009 applies, in what circumstances the deceased came by her death.

Michael Parke died at 13.10 on 6 December 2012 at the West Cumberland Hospital, Whitehaven, following the insertion of a nasogastric tube into his left lung resulting in Mr Parke developing aspiration pneumonia from which he died.

3. The deceased died from aspiration pneumonia. The pneumonia developed because a Nasogastric Tube was placed in such a way as to enter the left lung instead of the stomach. In the course of the insertion resistance was felt. Trust policy required that where resistance was felt the nasogastric tube should be removed and reinserted. However the nasogastric tube was left in situ. An x-ray was taken in order to confirm the correct placement of the nasogastric tube. The x-ray clearly showed that the end of the nasogastric tube was situated in the left lung. The x-ray was mis-interpreted and feeding via the nasogastric tube was authorised. The failure to note this incorrect placement amounts to neglect. The Trust policy was inadequate and incorrectly assumed that doctors across the Trust were competent to interpret chest x-rays and failed to require doctors to either undertake training or to evidence their competence. The policy failed to require the completion of a sticker that included the anatomical 4 point checklist recommended in the 2011 NPSA alert. These failures amount to systemic neglect. 140 mls of medication and food was administered via the tube and entered the deceased's lung resulting in the development of the pneumonia as a result of which he died.

Michael Parke suffered from chronic liver disease and was on 2nd November 2012 admitted to West Cumberland Hospital intensive therapy unit. On 5th November it was decided that a nasogastric tube should be fitted as part of his care. This was inserted the same day. An x-ray was taken to confirm the position of the tube. This image was later reviewed by a doctor who confirmed the tube was in the stomach and that feed could be administered. He subsequently deteriorated and when examined by a consultant the following morning the tube was found to be in the lung and was removed. His health did not improve and he died on 6th December 2012.

I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.