Retired firefighter died after nasogastric tube misplacement

In a heart breaking case, a great-grandfather, was admitted to the Royal Albert Edward Infirmary in Wigan with an infection on December 27th last year. Subsequent brain scans revealed he had suffered a minor stroke. Dr. Habib Rehman, a hospital consultant, noted that the patient had trouble eating and drinking following his admission.

On January 17th, a nasogastric tube was inserted to administer medication, food, and fluids. This tube, meant to travel from the nose to the stomach, unfortunately ended up in Mr. Butler's left lung. An X-ray was taken to verify the tube's placement, but a junior doctor, untrained in this procedure, misinterpreted the image.

Over a 15-minuteperiod, 150 to 200 millilitres of fluid were pumped into the patients’ lungs, causing him to develop chest pains. Dr. Rehman confirmed that such a misplacement is classified as a "never event" by the NHS, meaning it should never occur.

The hospital’s head of governance revealed that the involved doctor had not received training to confirm the nasogastric tube's placement and was unaware of the available training. The investigation highlighted significant gaps in training and procedural checks, but Ms. Heath did not provide information on any disciplinary actions taken against the doctor.

This tragic incident underscores the critical need for improvements in the technology used to determine the correct position of a nasogastric tube as well as comprehensive training and strict procedural adherence to prevent such devastating errors in healthcare settings.