A DOCTOR at Worcestershire Royal Hospital incorrectly inserted two tubes into a critically ill patient, who later died, a report has found.

A report into the ‘never event’ presented to the board of Worcestershire Acute Hospitals NHS Trust on Thursday, May 28 showed the unnamed patient had been admitted to the Intensive Critical Care Unit at the Royal on Saturday, January 24 after being treated for suspected pneumonia.

He was said to be extremely thin and needed help breathing. A doctor – who has also not been named and has since left the trust – inserted a feeding tube intended to feed through to the stomach, but it was found the next day to have been somewhere in the chest cavity, despite a previous X-ray suggesting it had been placed correctly.

The same doctor also incorrectly placed a catheter into an artery rather than a vein, putting the patient at risk of a stroke.

Although the mistakes were spotted and rectified the next day, the patient did not respond to treatment and died, with a post-mortem showing he had a tumour blocking his oesophagus.

The report said one of the reasons for the mistake was that the feeding tube was opaque, meaning it was difficult to spot on an X-ray. The trust has since replaced all tubes with versions with a metal strip all the way down so the entirety of the tube can be seen on an X-ray.

Speaking at Thursday’s meeting the trust’s interim chief medical officer Andy Phillips said ultimately nothing could have been done to save the patient as it would have been impossible to feed a tube into the patient’s stomach as a result of the tumour, but lessons needed to be learned from the incident.

“Very sadly whatever happened they were going to die,” he said.

“But we have to learn lessons from this.

“This X-ray was quite complex and we now use the tube which have metal lines all the way down, which we should have done anyway.

“We have also recognised difficult X-rays require help from more experienced staff.”

Deputy chairman John Burbeck said it was important opaque tubes and all other outdated equipment was removed from use.

“This isn’t the first time we found some of the equipment is outdated and we should have stopped using it.

“Have we got robust enough processes to make sure elsewhere in the organisation we are not using outdated equipment?”

As well as the new tubes, staff are also being given special training on carrying out X-rays.

A full investigation is carried out whenever a ‘never event’ occurs. In February 2009 a surgeon at Redditch’s Alexandra Hospital left forceps inside a mother-of-four during an operation. The error was not spotted until three months later.