NEW EQUIPMENT has been introduced after a bungling A&E doctor incorrectly inserted two tubes into a critically ill patient.
Worcestershire Hospitals Acute NHS Trust has purchased feeding tubes with an X-ray sensitive tip after the un-named doctor failed to spot the error.
The board was was told ‘Doctor A’ inserted a nasal feeding tube into the patient’s chest cavity following two previously failed attempts and despite performing similar procedures hundreds of times.
The tube was then declared as correctly placed, despite a close inspection of an X-ray revealing it was not.
The doctor also inserted a central line to pass through drugs to help the patient’s blood pressure. But instead of placing it into a vein, he put it into an artery, putting the patient at risk of a stroke. Further mistakes such as failing to document ultrasound tests, noticing the error on more X-rays and incorrectly inserting the feeding tube the next day also took place.
It was not until the following day when care was handed over to a consultant at the Worcestershire Royal that the misplaced lines were noted. However, the patient, already seriously ill, subsequently died.
The incident took place in January this year and follows abnormally high death rates in A&E, particularly at the trust’s Alexandra Hospital in Redditch.
The doctor has since left the trust.
Andy Phillips, interim chief medical officer, said the hospitals were never totally safeguarded, despite good practices.
He added the chances of this happening increased because the patient had an unknown large mass at the bottom of his gullet which would interfere with the tube going through to the stomach.
But he said: “If we had followed a robust process to use a proper tube and recognised the information in the X-ray, we would have stopped it.”
John Burbeck, deputy chair and non-executive director, said this was not the first time the trust had been using out-date equipment, while Andrew Sleigh, non-executive director, said he was concerned protocols were not being followed.
Chris Tidman, acting chief executive, agreed the trust’s equipment management system needed to be looked at and would be passed on to the quality and governance committee.
