Inquest told doctor overruled senior nurse's request for X ray
A doctor ignored advice from nurses about a wrongly placed feeding tube, which contributed to the death of a patient at a London hospital, an inquest heard this week.
A elderly woman with dementia died from a combination of natural disease, stroke and the “misplacement” of a feeding tube into her lung due a hospital blunder, a coroner has said.
Andriana Georgiou, an 84-year-old grandmother, contracted pneumonia and died 11 days after the error in December 2012 at the Homerton University Hospital in east London where she was being treated for a stroke.
Finnish trained consultant Dr Kari Saastamoinen made an “error” in using the “whoosh” test to verify wrongly that the tube was correctly inserted, Mary Hassell, senior coroner for inner London north told Poplar Coroner’s Court.
This was in spite of the test – where air flow is listened to in the tube to check whether it is in the right place – being the subject of three patient safety alerts since 2005, she said.
“The senior nurse asked the doctor for a check X ray but he opted instead to perform a whoosh test and he was then satisfied that the tube was in the right place – and feeding began,” Ms Hassell said, returning a narrative conclusion.
“It was not – a patient safety alert on February 21, 2005 and two subsequent alerts directed that the practice of using a whoosh test to check the position of a naso-gastric tube must cease immediately.”
The inquest also heard that the Homerton Hospital had drawn up policy ruling out the use of whoosh test after the first patient alert was issued in 2005.
The error was made on the morning of 4 December that year, but was not discovered until that evening, the inquest heard.
Nearly two litres of fluid had to be drained from her pleural cavity as a result. The error occurred in spite of there being “good” systems in place at the Homerton Hospital, Ms Hassell said.
She added: “Dr Saastamoinen was in contravention of the firm advice of a senior nurse, in contravention patient safety alerts dating back seven years, and in contravention of the hospital trust’s clear policy.”
However, she found Dr Saastamoinen not guilty of gross negligence after saying she could not return a verdict of unlawful killing.
Dr Saastamoinen told the inquest he had learned the “whoosh test” at medical school in Finland and had used it on several occasions in that country without problems.
He argued he has not been aware at the time that it was trust policy for a patient to go for a chest X ray where a litmus test indicated that there could be a problem, he said.
In December a further patient safety alert was issued by NHS England on the use of placement devices for inserting nasogastric tubes, following two recent patient safety incidents.
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