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Investigation and inquest
On the 20th September 2019 I opened an investigation touching the death of Amarbai Bhudia, aged 63 years old. I opened an inquest on the 14th October 2019. The inquest concluded on the 3rd November 2020.
The conclusion of the inquest was a narrative conclusion, which I have utilised below to describe the circumstances of death.
The medical cause of death was;
1a Aspiration of Gastro-intestinal Contents
1b Small Intestinal Pseudo-obstruction
1c Ulcerative Colitis treated with Colectomy
Circumstances of the death
“Mrs Amarbai Bhudia was admitted to hospital with abdominal pains and vomiting on 16th September 2019.
Mrs Bhudia was assessed to be suffering from a sub-acute small intestine obstruction and was admitted for ward-based, conservative management, incorporating;
1. Nil by mouth,
2. I/V Fluids,
3. A naso-gastric tube to decompress her stomach. Temporary clamping of the tube to facilitate a contrast CT scan, followed thereafter with 2-3 hourly aspiration of the NG tube.
4. Catheterisation.
The instruction to aspirate was not recorded in clinical notes. Mrs Bhudia's NG tube was not aspirated. On the morning of 17th September 2019 Mrs Bhudia collapsed and suffered a cardiac arrest caused by aspiration of gastro-intestinal contents.”
Coroner’s concerns
1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
2. Nursing staff had no clinical instruction as to how to manage the NG tube.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff.
Information checked against the published report and official responses