Hospital “Never Event” Led to Patient’s Premature Death

Lanyon Bowdler was instructed to investigate a potential claim arising from the death of a woman in her 70s following the misplacement of a nasogastric feeding tube in 2018. Our client was the woman’s daughter. The misplacement of the feeding tube meant that our client’s mother received unintentional feeding into her lung which led to her deterioration and tragic death.

Our client’s mother had been admitted to hospital in connection with pre-existing medical conditions. Unfortunately she also developed pneumonia whilst in hospital and her condition was frail. She became very unwell and the decision was made to insert a nasogastric feeding tube as she needed nutritional supplementation. There was a delay in placing the tube and when this was eventually placed, no chest x-ray was taken to confirm correct placement.

However, when feeding started through the NG tube, our client’s mother experienced significant chest pain and the feed was stopped. She then had a chest x-ray which confirmed that the NG tube had been placed in the left lung and needed urgent removal. Pursuant to its duty of candour, the hospital discussed the incident with our client and apologised for the error.

Unfortunately, as a result of the feed being delivered into the left lung, our client’s mother deteriorated needing transfer to intensive care. She sadly passed away approximately 24 hours later.

The defendant hospital trust carried out an internal investigation during which the nature of the incident was described as a “Never Event” (“Never Events” are serious incidents which are entirely preventable). Care and service delivery problems were also identified, including the failure to comply with relevant patient safety alerts. A significant element of this failure was a result of staff not having the appropriate skills and knowledge in the management of NG tube placement. There was also an inquest into the death. One of the causes of death listed was aspiration pneumonia.

In light of the serious nature of the incident, and the findings from the hospital trust’s own internal investigation and from the inquest, we wrote to the defendant hospital trust at an early stage to invite them to make full admissions of liability. The allegations of negligence related to the siting of the NG tube and the failure to verify correct placement before commencing the feed. As a result of these failings, our client’s mother received unintentional nasogastric feeding into her left lung which caused additional pain and suffering, aspiration pneumonia and respiratory deterioration which contributed to and accelerated her death. 

The defendant responded to make full admissions of liability. An offer of settlement was made at the same time, which was accepted by our client. Of course, no award of compensation is ever enough to compensate a bereaved family for the loss of a loved one, but it is hoped that by bringing these issues to light and by raising awareness that future deaths will be prevented.