Patient dies after tube reinserted

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 documentation.

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 awareness.

''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.

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