An incorrectly inserted nasogastric tube caused the death of
a recuperating neurosurgery patient at Dunedin Hospital,
Otago Southland coroner David Crerar has found.
Anne Eleanor Holdom, of Alexandra, died in Dunedin Hospital
on June 20 last year after a nurse tried to reinsert a tube
the patient had removed from her nose, only to have it pass
through a recently operated area, penetrating the brain stem.
After the ''devastating'' fatal injury, she was placed in
palliative care, and died the next day.
''In attempting to replace a nasogastric tube which had been
removed, a nurse in charge of the care of Anne Holdom
accidentally allowed it to pass through an area where bone
had been removed to enable the surgery, the site of the bone
removal having [been] repaired and thus created a weaker
area,'' Mr Crerar's written findings released yesterday said.
Ms Holdom (76) was admitted to Dunedin Hospital on May 1
suffering vision problems. An MRI scan showed a large
pituitary tumour. Following two surgical procedures to remove
it, Ms.Holdom was discharged on May 16.
Due to a deterioration of her condition, she was readmitted
at the end of May. A CT scan showed a large amount of
pneumocephalus due to a cerebral spinal fluid leak. The fluid
was drained, and a nasogastric tube inserted to supply
nutrition, fluid, and medication.
Inserted by an ear, nose and throat surgeon, it was placed
with added caution because of increased risk of passing the
tube into the brain. Two days later, despite her wrists being
restrained to reduce the risk of its removal, Ms.Holdom
pulled out the tube. A nurse attempted to reinsert it,
resulting in fluid and blood coming out of the nose. Before
the incident, she had been recuperating well.
An internal review raised problems including: patient
handover and communication issues; decision-making processes;
the appropriate level of physical restraint for confused or
delirious patients; documentation protocols.
A note of direction of what to do to replace Ms.Holdom's tube
was overlooked in the case notes.
Hospital policy about nasogastric tubes was also overlooked
because it was in effect ''buried in other documentation'',
reflecting the complexity and volume of policy and procedure
Staff lacked experience inserting nasogastric tubes in this
context due to few cases.
Mr Crerar said the Southern District Health Board had
apologised, conducted a proper investigation and made no
attempt to ''cover up'' the incident.
He recommended the board continue the process it had started
in improving its protocols.
Patient services medical director Dick Bunton said the
''sad'' case had greatly affected staff, and had increased
''We've certainly made sure that the general education about
the nasogastric tubes is very much to the forefront,
particularly in that neurosurgical department."
The nurse had not realised how fragile the area would be more
than a month after the tumour removal surgery, he said.