Pensioner died at Telford hospital after feeding tube was wrongly inserted into chest

Retired electrical engineer Maurice Dennis Nuttridge, 82, died at Princess Royal Hospital in Telford on January 8 this year, after the nasogastric tube was wrongly put into his pleural cavity.

It meant that for 24 hours, food and medication was being pumped into his chest, shrinking his lung capacity and increasing the chance of infection. Mr Nuttridge, of The Farthings, Shrewsbury, died of aspiration pneumonia.

Mr Jon Lacy-Colson, a consultant surgeon at Shrewsbury and Telford Hospitals Trust, gave evidence at Mr Nuttridge's inquest at Shirehall, following an investigation into the "never event" which contributed to Mr Nuttridge's death. He said a doctor x-rayed Mr Nuttridge after the tube was inserted, and was satisfied that it had been done correctly. Mr Lacy-Colson said that what happened "weighs heavily" on that doctor's mind.

Mr Nuttridge's son Phillip asked Mr Lacy-Colson if the consultant on rounds the next morning should have checked his father's tube. Mr Lacy-Colson said it would only be a matter for the consultant if a doctor had raised concern over the tube, though the consultant's personal standard was that he normally would. He added that the consultant was "rushed of his feet" and "felt bad about the fact that he didn't" check the tube.

A working group has been created and the hospital has hired a safety specialist to make sure immediate actions are taken following the incident. The hospital will also use both PH testing, to check for high acid levels on the tube to ensure it is actually in the stomach, and x-rays to make sure tubes are correctly placed – rather than one method or the other. If one of the methods shows an anomaly, a consultant must investigate.

John Ellery, senior coroner for Shropshire, Telford and Wrekin, recorded a narrative conclusion of death by natural causes, contributed to by the misplacement of a nasogastric tube.