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Doctors misread patient's x-ray
AN ELDERLY woman died in hospital after a feeding tube was inserted into her lung rather than her stomach, an inquest heard.
Margaret Mary Burton, 90, died from lung infections three days after the mistake at the University Hospital of North Tees, in Stockton.
Yesterday, the inquest in Middlesbrough heard that nurses raised concerns after the feeding tube was inserted into Mrs Burton’s nose and readings showed that food was failing to reach her stomach.
They requested an x-ray, which was viewed by a doctor, who wrongly concluded that the tube was fine.
However, by the time it was discovered that the tube had gone into a lung rather than Mrs Burton’s stomach it was too late and she died on March 31, 2009.
Dr Rajkumar Arasappan told the inquest that he had misinterpreted the x-ray, explaining that because it showed the tube was below the diaphram he believed it had entered the stomach.
“I hadn’t had any formal training, there was no formal training. I now realise there was a mis-interpretation of the x-ray,” he added.
The inquest heard that Mrs Burton, who lived at Park House Residential Home, in Stockton, had suffered a second and very serious stroke and also had heart problems and was frail.
Dr Richard Gordon Dent, who was asked by Cleveland Police to investigate her death, read his conclusions to coroner Michael Sheffield.
He said that in his opinion the North Tees NHS Trust policy was fine, there was no criticism of the speech and language or radiology departments and only very minor criticism of nursing staff over the less important aspects of note keeping.
However, he did say that a mistake was made in reading the x-ray, adding: “Any ordinary, skilled medically qualified person would be able to see the tube was in the wrong position.”
Dr Dent has been involved in improving the system of inserting medical tubes through the nose across the UK.
In a survey of 200 doctors, only 30 per cent had received any training in the simple procedure.
It has emerged that there were 21 deaths and 79 serious incidents resulting from tubes being wrongly inserted between 2003 and 2005 across the country, although about 27,100 such insertions were made annually.
The hearing was told that North Tees Hospital had already introduced improved checks on the knowledge of feeding tubes among its doctors and nurses and regular training is given.
The inquest continues today.
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