Hospitals to change procedure after Shropshire journalist's death
The county’s hospitals are introducing a new protocol after the death of a respected Shropshire journalist.
John Michael Robinson, known as Mike, died at Royal Shrewsbury Hospital on September 8.
The 65 year old from Oswestry had been diagnosed with oesophageal cancer and later had a feeding tube fitted through his abdomen into his bowel.
An inquest, which took place at Shirehall yesterday, heard the tube moved from its place in the bowel and the contents from the feeding tube went into Mr Robinson’s body, leading to sepsis and his death.
Recording a narrative conclusion John Ellery, coroner for Shropshire, Telford & Wrekin, said a failure to monitor the position of the tube had led to the Oswestry Cricket Club chairman's premature death.
He said: “Mr Robinson has died not because of cancer but from consequences following this surgical procedure.
“There was a failure to monitor its position and a failure to recognise that it had become displaced.
“The displacement of the tube led to Mr Robinson’s premature death because he would not have died when he did had the tube not been displaced and had the nutrients not gone outside his abdomen leading to sepsis from which he died.
“The trust is now in the process of putting in measures to monitors the placement past the installation of the feeding tube.”
Jon Lacy-Colson, consultant colorectal surgeon at Royal Shrewsbury Hospital, said he had no doubt that the tube was in the right place when the operation was being performed.
He said: “I have no doubt that it was in the bowel as it was done under direct vision.
“Post mortem it had shortened and was outside the bowel.
“It relies on somebody checking and recording to make sure it was in place afterwards and we found no record that it was checked.
“The trust does not currently have a routine protocol, we feel moving forward it’s appropriate for us to have a routine protocol for staff to follow.
“It will now be monitored to make sure it hasn’t moved.”
The inquest also heard that Mr Robinson’s family had concerns over the speed of his diagnosis.
Manel Riera, consultant surgeon at the Royal Shrewsbury Hospital, was the endoscopist Mr Robinson was referred to on a routine basis by his GP.
Mr Riera said that Mr Robinson mentioned he had trouble swallowing some food.
Mr Riera said: “I found him to have a malignant legion in his oesophagus. I took numerous biopsies and upgraded it from routine to a cancer referral.
“The tubes leading to his lung were involved which made the tumour inoperable.
“Mr Robinson was made aware that the care was going to be palliative as it could not be cured.
Mr Riera added: “It only breaches national cancer waiting targets by nine days. This was the result of a necessary and appropriate delay.
“On balance he would still have advanced cancer unfortunately if he’d waited two weeks rather than a routine referral, I don’t believe this would’ve changed his outcome.”
