Source · Prevention of Future Deaths
Frederick Davidson
Ref: 2013-0258
Date: 14 Oct 2013
Coroner: Martin Flemimg
Area: Surrey
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Date
14 Oct 2013
56-day deadline
23 Mar 2014 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 2
Coroner's concerns
The coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
View full coroner's concerns
During the inquest who conducted the SI Report provided very helpful evidence and the following concerns were highlighted: ‐
Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures Unexplained and important gaps in the clinical notes Breakdown in communication between the junior doctor and consultant. The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. Delay in the forwarding and receipt of x ray reports from radiology
I would ask that you consider the guidelines on the urgency of x rays and staff training needs when a pneumothorax is suspected and/or concerns raised about the placing of a nasogastric tube.
Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures Unexplained and important gaps in the clinical notes Breakdown in communication between the junior doctor and consultant. The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. Delay in the forwarding and receipt of x ray reports from radiology
I would ask that you consider the guidelines on the urgency of x rays and staff training needs when a pneumothorax is suspected and/or concerns raised about the placing of a nasogastric tube.
Report sections
Investigation and inquest
On 28th December 2011 I opened the inquest into the death of Frederick Davidson, who at the date his death was 80 years old. The inquest was resumed and concluded on 23/9/13. I found that the cause of death to be:
1a – Aspiration pneumonia secondary to recurrent epileptic seizures complicated by misplacement of nasogastric tube 2 – Ischaemic heart disease mixed Alzheimer’s and vascular dementia.
I concluded with a narrative conclusion as follows: On 9/12/11 Frederick Davidson who had a history of advanced dementia and chronic seizures was admitted to Epsom General Hospital with aspiration pneumonia. It was subsequently discovered that he had developed a pneumothorax as a result of being fed via an unnoticed and incorrectly placed nasogastric tube, which on the balance of probabilities hastened his death on 20/12/11.
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1a – Aspiration pneumonia secondary to recurrent epileptic seizures complicated by misplacement of nasogastric tube 2 – Ischaemic heart disease mixed Alzheimer’s and vascular dementia.
I concluded with a narrative conclusion as follows: On 9/12/11 Frederick Davidson who had a history of advanced dementia and chronic seizures was admitted to Epsom General Hospital with aspiration pneumonia. It was subsequently discovered that he had developed a pneumothorax as a result of being fed via an unnoticed and incorrectly placed nasogastric tube, which on the balance of probabilities hastened his death on 20/12/11.
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Circumstances of the death
Frederick Davidson was admitted to Epsom General Hospital on 9/12/11 upon referral by his consultant doctor, after he was found to have developed aspiration pneumonia. He had suffered two seizures the week before his admission. He was fed via a naso gastric tube which was misplaced and unnoticed for 24 hours notwithstanding several chest x rays taken. As a consequence he suffered a pneumothorax but despite treatment he succumbed and died on 20/12/11.
Copies sent to
DirectorChief Coroner Signed: Martin Fleming, HM Assistant Coroner for SurreyDATED this 14 day of October 2013
Inquest conclusion
On 9/12/11 Frederick Davidson who had a history of advanced dementia and chronic seizures was admitted to Epsom General Hospital with aspiration pneumonia. It was subsequently discovered that he had developed a pneumothorax as a result of being fed via an unnoticed and incorrectly placed nasogastric tube, which on the balance of probabilities hastened his death on 20/12/11.
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Report details
- Reference
- 2013-0258
- Date of report
- 14 October 2013
- Coroner
- Martin Flemimg
- Coroner area
- Surrey
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Mar 2014 (estimated from the Judiciary.uk publication date).
Sent to
- Department of Health and Social Care
- Epsom and St Helier University Hospitals NHS Trust