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Tuesday, 30 June 2015

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Hospital patient had feeding tube in lung

A HOSPITAL patient died days after a wrongly placed feeding tube was found in their lung.

The catastrophic error was one of nine “never events” – mistakes so bad they should never have taken place – recorded at the University Hospitals of Morecambe Bay NHS Foundation Trust during the three-year period spanning 2011, 2012 and 2013.

In December 2013 it was revealed that 150 patients nationally had been harmed by such incidents between April and September of that year, including three within the trust which runs Furness General Hospital.

UHMBT refused to provide more details of the incidents, including in which hospital they had occurred.

The details of these nine incidents were supplied in reponse to a Freedom of Information request lodged by the Evening Mail following last year’s report.

UHMBT faced a clinical negligence claim for one of the events, the misplacement of a naso/oro gastric feeding tube at its Royal Lancaster Infirmary site in 2011.

Confirming details of the incident the trust said: “The patient had an NG tube in situ and had been fed through this tube and feeds had been running for four hours in total.

“The patient experienced right-sided chest pain and an urgent chest x-ray showed the NG tube in the right lung. The patient died two days later.”

Of the remaining never events, three took place in 2012, with the remaining five recorded in 2013.

Of all nine incidents, only one occurred at FGH – a “retained foreign object” reported between April and September last year.

The trust said: “A peripherally inserted central catheter, a type of intravenous catheter, was removed in a patient showing signs of sepsis.

“When an X-ray taken to check the patient’s condition was viewed, it was noted that a previously placed PICC was still in situ but had migrated several centimetres proximally and would require surgical exploration for retrieval.

“This catheter should have been removed sooner, and the fact that not all the catheter had been retrieved should have been noted at the time.”

Other major errors recorded in the last three years included an operation being carried out on the wrong patient, wire being left in someone’s ureter following kidney surgery and two incidents of swabs being left inside mothers following childbirth.

Trust medical director, George Nasmyth, said: “We take these events extremely seriously, investigate them thoroughly and ensure that we share learning from each to minimise any re-occurrence of a similar event.

“The safety of our patients is our priority and we actively encourage members of staff to report any events which take place where they have concerns that patient care may have been compromised.”


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