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Jury Returns Narrative Verdict After Feeding Tube Wrongly Inserted Into Pensioner’s Lung

Medical Negligence Solicitor Calls For Investigation


An inquest jury has heard how an 81 year old pensioner died after nursing staff at a BUPA care home wrongly inserted a feeding tube into his lung. The mistake went undetected by care staff for more than four hours and was only discovered when his daughter visited the home to find her father collapsed in bed and unable to breathe.

Ronald Kemble from Halesowen in the West Midlands was rushed to Russells Hall Hospital in Dudley where he died five days later on December 1st 2007. 

Returning a narrative verdict, The jury and HM Coroner for Sandwell, Dudley and Walsall, Robin Balmain, heard that the error had occurred, in part, because staff at the BUPA managed Warrens Hall Nursing Home in Oakham Road, Tividale were using outdated nursing procedures which had been discredited more than two years earlier by the National Patients Safety Agency (NPSA) as being unsafe and unreliable.

Following the fatal incident, a police investigation was launched but this was later closed and no charges were brought against the care home or its staff.

Now Victoria Blankstone, a medical law expert, with Irwin Mitchell solicitors is calling for such a serious breach to be investigated by the Nursing and Midwifery Council and for BUPA to carry out an urgent nationwide review of its procedures to safeguard other vulnerable, elderly patients in its care.

The jury was told that widower, Ronald Kemble, a retired manager with Bookers Cash & Carry in Stirchley, had been a fit and active man, prior to suffering a massive stroke at his home on 10th October 2007. As a result Mr Kemble required full time nursing care and due to problems swallowing, needed to be fed via a nasogastric feeding tube. Following seven weeks in hospital, arrangements were made for him to be transferred to the Warren Hall nursing home.

On Monday 26th November 2007, just two days after his arrival, two nurses were carrying out a repositioning of Mr Kemble’s feeding tube, when they wrongly inserted it into his right lung rather than his gullet leading to the stomach.

As a result of the misplaced feeding tube, a large amount of liquid was inserted into Mr Kemble’s lung. The alarm was only raised when his daughter, Joanne Yale, arrived at the home just after 5.15pm to find him sprawled across the bed and unable to breathe. Mr Kemble was rushed to Russells Hall Hospital where, despite the efforts of medical staff, he died three days later. Cause of death was recorded as aspiration pneumonia.

The inquest heard that nurses at Warren Hall nursing home had used an outdated method of checking the position of the feeding tube, known as a ‘bubble’ or ‘air’ test (also known as a whoosh test.)

The technique, where air is introduced through the tube and then monitored with a stethoscope to indicate whether the tube has been positioned correctly, was once routinely used but, following advice from the Healthcare Products Regulatory Agency in June 2004 and a subsequent safety alert from the NPSA on 21st February 2005, the procedure was considered to be unreliable and unsafe.

Victoria Blankstone, a medical law solicitor with law firm, Irwin Mitchell, who is representing Mr Kemble’s family, said: “This was a tragic error which could have been avoided.

“Joanne put her trust in staff at Warrens Hall and, indeed had specifically chosen this nursing home to look after her father after being assured by the staff that they could manage his feeding tube.

“I am very concerned that following evidence heard during the inquest, it would appear that there was no BUPA policy in place at Warrens Hall relating to the insertion and correct positioning of nasogastric tubes and the safety alert issued by the NPSA did not appear to be on file. Both BUPA and their nursing staff have a fundamental duty of care to ensure that nursing procedures are kept up to date and are adhered to. I very much hope that as a result of this incident procedures have been tightened up to ensure that such a tragedy cannot occur again.”

Mr Kemble’s only daughter, Joanne Yale, said: “My Dad meant the world to me. He had always been a very fit and active man. Although he was 81 you’d never have known it to look at him He still drove a car, did his own shopping and, only the day before he had his stroke, he’d been out in the garden mowing the lawn.

“Following the stroke, the doctors told me his long term prognosis wasn’t good and that he needed 24 hour nursing. I was determined to make sure he got the best possible care and checked out five separate care homes before deciding on Warrens Hall after they told me they were able to cope with his needs and knew how to deal with a feeding tube.

“I feel so angry that they let both Dad and me down so badly. They robbed me of the little time that I had left with him.”