Wigan retired firefighter died after hospital tube error

A retired fireman died after a feeding tube was mistakenly inserted into his lungs instead of his stomach, an inquest has heard.

Terry Butler, 83, from Wigan, Greater Manchester, developed pneumonia as a result of the error and died a month later on 16 February.

Bolton Coroner’s Court was told an untrained junior hospital doctor failed to spot the mistake on Mr Butler’s X-rays.

Coroner Alexander Frodsham concluded Mr Butler died as a result of misadventure contributed to by neglect.

Described as a “pillar of the community”, Mr Butler had joined the fire service in his 20s and retired in the 1990s after suffering an injury.

He had also served as a local councillor for 45 years and as a school governor.

The great-grandfather had been admitted to the Royal Albert Edward Infirmary in Wigan with an infection on 27 December last year, and brain scans showed he had suffered a minor stroke.

Dr Habib Rehman, a hospital consultant, said after Mr Butler’s admission he had difficulty eating and drinking.

On 17 January a nasogastric tube was inserted in a procedure to administer medication, food and fluids.

The tube is inserted into the nose and down the back of the throat to the stomach, but in Mr Butler’s case the tube had gone into his left lung.

An X-ray was taken to ensure the tube was in the right place, but the image was “inaccurately interpreted” by a junior doctor, who had had no training in checking the procedure, the inquest heard.

As a result, 150 to 200 millilitres of fluid was pumped into Mr Butler’s lungs over a 15-minute period, before he began to develop chest pains, Dr Rehman said.

Mr Frodsham, assistant coroner for Manchester West, asked Dr Rehman: “In terms of misplacement of the tube, this features on the NHS list of ‘never events’. This should never happen?”

“Yes,” Dr Rehman said.

Nicola Heath, head of governance at the hospital, said an investigation identified the medic involved had not been trained to confirm the correct placement of a nasogastric tube, was not aware training was available and had wrongly interpreted the X-ray images.

Ms Heath said she had no details on whether the doctor had been disciplined by the hospital or medical authorities.

The inquest heard there were two further incidents involving nasogastric tubes at the hospital – in 2017, when the medic who interpreted the X-ray had not been trained, and in 2019, when the doctor interpreted the image in error.

After the 2017 incident, nasogastric tube placement training became mandatory for junior doctors, but the medic in Mr Butler’s case, “slipped through the net” as he was classed as a “clinical fellow” rather than a junior doctor.

Stephen Jones, representing the Butler family, said this was a “gross failure”, adding: “This doctor should have been trained and wasn’t.”

Nichola Halpin, representing the hospital, said: “This is not a matter the trust has taken lightly. Action has been taken.”

Elizabeth Harrison, Mr Butler’s daughter, told the inquest: “We were told terrible news, dad only had a fifty-fifty chance of survival.

“He was very much loved by all his family and those who knew him.

“The family are struggling to come to terms with his death.

“We feel he could have gone on to live for a few more years. We feel dad unduly suffered.”

Professor Sanjay Arya, medical director at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, said: “We extend our deepest sympathies and condolences to Mr Butler’s family and friends.

“We always try to do our best for our patients but on this occasion, standards of care were not met, as a result of which we failed the patient and the family, for which we are truly sorry.”