Terry Butler, 83, from Wigan, Greater Manchester, died after a feeding tube was mistakenly inserted into his lungs instead of his stomach, an inquest has heard.
The error, which led to pneumonia, resulted in Mr. Butler’s death on 16 February. At Bolton Coroner’s Court, it was revealed that an untrained junior doctor failed to spot the mistake on Mr. Butler’s X-rays. Coroner Alexander Frodsham concluded that Mr. Butler died as a result of misadventure contributed to by neglect, highlighting a serious case of NHS negligence.
Mr. Butler, a respected community figure, had joined the fire service in his 20s and retired in the 1990s. He also served as a local councillor and school governor. He was admitted to the Royal Albert Edward Infirmary in Wigan on 27 December last year with an infection, and brain scans showed he had suffered a minor stroke.
Untrained Doctor and Misinterpreted X-Ray
Due to difficulty eating and drinking, a nasogastric tube was inserted on 17 January to administer medication, food, and fluids. However, the tube was mistakenly placed in his left lung. An X-ray to confirm the tube’s placement was “inaccurately interpreted” by a junior doctor with no training in the procedure, according to BBC News. As a result, 150 to 200 milliliters of fluid were pumped into Mr. Butler’s lungs, leading to severe complications. This incident is categorised as a “never event” by the NHS, indicating it should never occur.
Nicola Heath, head of governance at the hospital, stated that the doctor involved was not trained to confirm the correct placement of the nasogastric tube and had misinterpreted the X-ray images.
Despite training becoming mandatory for junior doctors after similar incidents in 2017 and 2019, the medic involved in Mr. Butler’s case “slipped through the net.”
Elizabeth Harrison, Mr. Butler’s daughter, expressed the family’s anguish, stating, “We feel dad unduly suffered and could have lived for a few more years.”
Professor Sanjay Arya, medical director at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, offered an apology: “We extend our deepest sympathies and condolences to Mr. Butler’s family and friends. We failed the patient and the family, for which we are truly sorry.”
This tragic incident underscores the severe consequences of NHS malpractice and highlights the need for stringent training and oversight to prevent similar occurrences in the future. Cases like Mr. Butler’s amplify the critical issues within NHS negligence cases and the importance of proper medical training to avoid GP negligence.
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