Amanda Coulthard · Prevention of Future Deaths report

On 29th April 2015 I commenced an investigation into the death of Amanda Coulthard aged 57 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;
1b) Insertion of a nasogastric tube and administration of feed and medication into the right lung in the treatment of multiple sclerosis.

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

Amanda Coulthard died at 07.10 on 26th April 2015 at the Cumberland Infirmary, Carlisle following the insertion of a nasogastric tube into her right lung resulting in Mrs Coulthard developing aspiration pneumonia from which she 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 right lung instead of the stomach. The tube was inserted at 14.20 on 17th April 2015. An unsuccessful attempt to draw aspirate was made and an x-ray to confirm the nasogastric tube’s position was authorised. At 17.00 a further attempt to obtain aspirate was made in the absence of a second checker in breach of Trust Policy, training and national best practice. The pH of the aspirate was incorrectly read from a pH strip. These failings amount to neglect. This resulted in the misplacement of the tube being undetected. Feeding was commenced. 525 ml of liquid was administered via the tube and entered the deceased’s right lung resulting in the development of the pneumonia from which she died.

Amanda Coulthard suffered from multiple sclerosis. In April 2015 she was transferred from Penrith Hospital to the Cumberland Infirmary, Carlisle due to poor health and for further investigation. Her prognosis was not good. As part of her treatment plan it was decided that a nasogastric tube (NGT) be inserted to deliver nutrients and medicine. An NGT was fitted on 14th April and its position checked by x-ray. She pulled tubes out on 14th and 17th April 2015. On 17th April 2015 a fresh NGT was inserted. As no aspirate was obtained the plan was for an x-ray. Records note that aspirate was obtained and feed commenced. The x-ray was abandoned. She subsequently began coughing up blood. Shortly after midnight on 18th April 2015 an x-ray showed the NGT in the right lung. She was, in view of her condition, treated conservatively. She died on 26th April 2015.

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 are avoidable. Common themes in all were:
(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.