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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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Readers' comments (20)

  • michael stone

    '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.'

    Now, I'm 'assuming the clinical stuff as I go along here', but my main assumptions are simple:

    1) This tube reaches the stomach, a sample of fluid from the far end of the tube is what is being litmus tested, and that (see above) this was done in this case;

    2) The inside of the lungs, is nothing like as acidic an enviroment as the inside of a stomach - in particular, that although under rare circumsatnces a stomach can be much less acidic, lungs are almost never anywhere near as acidic as an 'acidic' stomach.

    So - as a litmus test was mentioned, and apparently raised a concern - presumably the test came back 'much too acidic for lungs': so what the heck, was going on there ?!

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  • Had I have been one of the nurses involved in delivering the feed to this patient. I would have refused outright to administer it. Nurses be warned, do not ever let anyone take you into the realms of poor practice.

    Case closed.

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  • tinkerbell

    Anonymous | 11-Jan-2014 1:41 pm

    Good for you, so would I. As a student I was stood by a doctor who was inserting a naso tube the wrong way round. I had no experience as still early on in training, or no experiences of previously doing this, as a psyche nurse on a general ward. When I pointed out it looked like he was putting it in the wrong way round, he asked, how do you know. I said 'cos on the packet it shows it should go in the other way round'.

    He said 'oh f*ck, thank you'.

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  • I hope that the nurse recorded his/her concerns and cascaded them to the rest of the nursing staff.

    One question though...

    If it had been the nurse that had made that mistake, would the nurse have 'got off' so lightly?

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  • michael stone | 11-Jan-2014 1:20 pm

    there is no fluid in the lungs under normal healthy circumstances so the litmus does not apply. Fluid in the lungs causes breathlessness and gives cause for rapid investigation!

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  • michael stone

    Anonymous | 11-Jan-2014 8:40 pm

    Well, there is moisture in the lungs - and this piece appeared to indicate that a litmus test had been performed, and had caused concern to the nurses if not to this medic.

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  • This happened to me back in the prehistoric 80's. I passed the NG tube, it was a difficult procedure. The guy went for an X-ray and I went off duty. The x-ray was NOT checked and feeding commenced. The guy died and I went to a coroners court.Strange how lessons have not been learned in the intervening years.

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  • Lessons have been learnt, they are just not being followed.....

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  • Michael I don't think he did the Litmus test at all. He did the whoosh test which is simply listening with a stethoscope. It is a totally unreliable method and went out of fashion years ago because it was clearly unsafe.

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  • If a Chest x-Ray is policy in this facility then, unfortunately, the nurse is guilty of proceeding with the feeding without the x-ray. In Canada, where I live, I would be held responsible as the RN.
    The nurse needs to insist that the hospital policy be followed, without the x-Ray the nurse is prohibited from proceeding with the feeding.

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  • why didn't a nurse carry out a test to verify the tube. perhaps they have more experience than anybody else.

    as far as lessons being learned, there should be an obligation to publish (1) what lessons have been learned; (2) what measures have been taken to demonstrate this and redress the problem; and (3) what improvements are being made to ensure the avoidance of similar errors in the future.

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  • 1. Judith Mallett,

    thank goodness for your policy and your nurses strenght of character to stand up to medics.

    2.Anonymous 12 jan 5.33pm.

    Policy is what is needed.

    This is not a new problem.
    Nurses need to think long and hard about their actions and if a patient is potentially at risk, they must have the professionalism and strenghth of character to refuse to participate. Documenting their reasons and passing it up the line.

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  • Fine-bore NG feeding tubes often cannot be aspirated to obtain fluid for a litmus test. If, however, this test had been carried out, it would have demonstrated that the aspirated fluid (potentially respiratory secretions from the lungs) was not acidic.

    As many patients who are NG fed require proton-pump inhibitors, however, their gastric secretions might not be acidic either, so in this instance - or when no fluid can be obtained for a litmus test - an x-ray would be the only way of determining the location of the end of the feeding tube.

    The article does not detail who actually administered the feed. Without evidence of the tube's location, nobody should have commenced feeding via the device - but whoever did so must be aware that their actions alone were what killed the patient.

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  • In paediatrics, NG tubes have to be tested each and every time they are used, whether for feeds or drugs (we don't tend to X ray). I'm not sure if this is the case with adult patients, but certainly I would not have fed that patient if I had not been sure of the tube's position. Anyone who has read the NPSA alerts should also know that litmus paper also went out along with the whoosh test several years ago because it is not sensitive enough to distinguish lung secretions from gastric fluid. Now pH paper has to be used and a pH of less than 5.5 is needed from the aspirate.
    This doctor's assertion that he had learnt and used the whoosh test in Finland with no problems is hardly a defence. I learnt and used the whoosh test without apparent problems since student days but I have changed my practice as a
    result of new evidence and guidance. Yes, it's not nearly as convenient and pH paper is a pain in the whatsit, but I would like to think a) the patients in my care are more important that my own convenience and b) I don't live in a retro bubble where I think what I learnt at uni was the only way to do things.....

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  • michael stone


    Sarah Brooklyn | 12-Jan-2014 1:35 pm

    Perhaps Sarah - but the article includes the bit below, which implies there was an issue: either policy says there should be a 'litmus test' performed and it wasn't, or it was performed, 'came back wrong' but was ignored. Either way, this doesn't inspire confidence !

    '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.

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  • It should be mandatory for every patient who has an NG tube passed to have a chest x ray done prior to it being used.

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  • Why use NG tube in the first place? Was it a temporary way of feeding the patient? Perhaps enteral feeding would have been a better option? Or was cost/time an issue?
    Do next of kin have any say in these situations? By that, I mean, whether the patient ought to be fed artificially? Did the patient give consent? Presume not if they had communication/cognitive issues?

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  • It sounds like the patient had stroke, which may have affected communications, cognition, swallowing and clearing airway. Even so NG tube maybe temporary, should not be a permanent fixture.

    I think from npsa guidelines, ph test is the recommendation, followed by check xray if gastric aspirate cannot be obtained (reduces radiation exposure, as patients might need loads of scans). Whoosh test, is good for hearing a whoosh sounds, but no certainty of positioning. Inserting air into NG tube could be used as part procedure of trying to free tip from stomach lining in attempt to obtain gastric aspirate.
    I would hope someone wouldn't start using NG feed, fluid, medications until sure of positioning, irrespective of who said to start feeding. Then start off slowly/small volumes, as small volumes of fluid in lungs Will cause severe breathing problems, so 2 litres definitely isn't good.

    Was this doctor a consultant, what about post med-school training ?
    I assume the doctor didn't start feed, but probably told a nurse to do it, however it could be possible, and still not be documented.

    Yes, I also think if a nurse did this, the consequences and publicity would be far worse.

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  • This is what we see in the 3rd world countries where the Doctors do not want to share the experience of the Nurses. We thank God with litigation coming up, things are changing. I still have to advice us as Nurses to follow scientific ways of practicing our dear and only profession.
    Thanks,
    Abubakar Mamman Ingawa
    From Nigeria

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  • Sadly old habits die hard amoungst health care professionals and this resistance to engaging in is evidence based practice is detrimental to the development of professionals as well as patient care.
    Without the knowledge we are ill equipped to defend the strength of character that questions unsafe practice!

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