Investigation after feeding tube inserted into patient's lung cavity at Telford hospital
An investigation is under way after a feeding tube, inserted through a hospital patient’s nose, ended up in their lung cavity rather than the stomach.
Arne Rose, medical director at the Shrewsbury & Telford Hospital NHS Trust (SaTH) told the trust's board that the patient, who was in intensive care at the Princess Royal Hospital, was given the tube and an X-ray was taken to confirm its position.
He said it was unclear whether the nasogastric tube was wrongly inserted or moved inside the patient later, but said some feeding fluid ended up in the pleural cavity surrounding a lung.
A report for the board said the incident was one of four “never events” recorded at the trust throughout 2020.
The investigation's findings will be reported back to SaTH’s Incident Review Group, Dr Rose added.
The report, co-authored by Dr Rose and Nursing Director Hayley Flavell, said: “There were six serious incidents reported in December 2020 and one never event.
“The never event related to a misplaced NG tube and is subject to a full investigation.”
Unusual
Dr Rose said: “This is a patient who had been admitted into intensive care and had an NG feeding tube placed and, in line with NHS guidance, had an X-ray to confirm the position of that.
“That X-ray was reviewed. The result of the X-ray was written in the notes of the time and feeding commenced.
“Further checks seemed to have also been done but, unfortunately, the NG tube did end up in the lung tissue and also some of the feed ended up in the pleural space, which is very unusual.
It is not clear exactly what happened.
“The NG tube appears to have either migrated or been misplaced in the first place, which is what we don’t know yet and is why we need to do an investigation.”
The report – which doesn’t state the age, gender or condition of the patient – says the incident led to an “immediate review of ITU [intensive treatment unit] protocols”.
Dr Rose explained that serious incident or “never event” investigations are always carried out by independent people unconnected to the original care of the patient.
