A retired Wigan firefighter has died after a tube failure in hospital

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

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

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

Coroner Alexander Frodsham concluded that Mr Butler died as a result of accident to which negligence contributed.

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 also served as a local councilor 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 December 27 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 January 17, 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 went into his left lung.

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

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

Mr Frodsham, deputy coroner for Manchester West, asked Dr Rehman: “In terms of tube misplacement, it is on the NHS list of ‘never events’. Should this never happen?”

Nicola Heath, the hospital’s head of governance, said an investigation found the doctor involved was not trained to confirm the correct placement of the nasogastric tube, did not know there was training available and misinterpreted 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 other incidents involving nasogastric tubes at the hospital – in 2017, when the doctor who interpreted the X-ray had not been trained, and in 2019, when the doctor interpreted the image by mistake.

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

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

Nichola Halpin, a spokeswoman for the hospital, said: “This is not a matter the trust has taken lightly. Measures have 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 much loved by all his family and those who knew him.

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

“We feel he could have lived a few more years. We feel that dad has suffered unjustly.”

Professor Sanjay Arya, chief medical officer 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, and we have failed the patient and family, for which we are truly sorry.”