Hampshire Dad-of-Two Died After Decompression Tube Wrongly Placed Into Lung Rather Than Stomach
A coroner has called for action to prevent future deaths after a patient died when a tube was incorrectly inserted into his lung – causing him to inhale stomach content.
Coroner Caroline Topping has issued a prevention of future deaths report calling on Health Education England and the National Institute for Health and Care Excellence (NICE) to set out what action it will take to improve patient care.
It follows the death of Reginald Bourn who died in Frimley Park Hospital, Camberley, after one-and-a-half litres of stomach content was sucked into his lungs. A tube intended to relieve pressure on his abdomen was wrongly inserted into his left lung rather than his stomach.
While recommendations calling for standardised national training for the insertion of nasogastric (NG) feeding tubes had been made in 2020, there was no training or guidance for NG decompression tubes – which drain fluid from the body - as used in Reginald’s case, the coroner’s report said.
Without action more patients were at the risk of dying, the coroner said.
The family of Reginald, of Blackwater, Hampshire, and their legal team at Irwin Mitchell – which helped secure answers at an inquest into his death – have welcomed the report.
Expert Opinion“Reginald’s family remain devastated by his death and circumstances surrounding it.
“Understandably they had a number of concerns over Reginald’s care in the lead up to his death. Sadly investigations into his care have validated those.
"As highlighted in Reginald’s case the misplacement of NG tubes can prove fatal.
“While nothing can make up for the hurt and pain his family are going through, the inquest and coroner’s report have provided Reginald’s loved ones with some of the vital answers they deserve. We welcome the coroner’s findings and hope they lead to improvements in patient safety.” Alice Webster, Medical Negligence Lawyer
Reginald was admitted to Frimley Park Hospital on 23 February, 2022, with severe stomach pain. Following tests, he was diagnosed with a blocked bowel.
On 24 February a NG decompression tube was inserted to relive pressure on his abdomen. However, shortly afterwards his condition deteriorated. He died that afternoon, aged 92.
An inquest at Surrey Coroner’s Court was told Reginald, a former aircraft engineer, died as a result of aspirating stomach content from his abdomen.
Recording a narrative conclusion at June’s hearing, the coroner ruled “the misplacement of the nasogastric tube more than minimally contributed” to the father-of-two’s death.
Sarah Bourn, 54, Reginald’s daughter said: “Dad was a wonderful person who was loved and adored by all his family. He was a devoted husband, father and an active grandfather supporting us all in many ways. He was never happier than when spending time with his family.
“There’s not a day goes by that we don’t miss him and think about him and his death has left a big void. Seeing him in hospital suffering and so helpless towards the end was terrible.
“Trying to come to terms with what happened to Dad in the lead up to his death has been incredibly difficult. Not having answers to our questions made everything much harder.
“The inquest and reliving what happened was distressing but our family take some comfort from at least now having answers as to why Dad died.
“Hearing about the coroner’s concerns was still a shock but if national training and guidance leads to improved healthcare for other families so these mistakes are not made in future, that would be something positive to hold onto after such a terrible experience.”
Reginald also leaves behind wife Jean, aged 90, son, Christopher, aged 56, and grand-daughter Imogen, 15 who he was devoted to supporting and caring for.