In a very tragic case, Russell-Cooke partner Dominic Fairclough acted at an inquest for the family of Brian Gilberthorpe who died following basic failings in medical care leading to a conclusion/verdict of death contributed to by neglect which is an unusual finding in an inquest of this nature.

The Facts of the Case

Brian Gilberthorpe was 75 years old on 17 December 2000 when he was admitted to Medway Maritime Hospital from his nursing home due to a suspected eye infection.

Brian was suffering from dementia and lacked capacity. He was finding it difficult to eat and in the circumstances his next-of-kin and brother, Steve was advised by the hospital that they needed to insert a nasal tube (NGT) to allow them to give feeds to Brian.

The tube was inserted and in line with hospital policy an x-ray was taken and reported on by a radiologist who advised that the tube had been misplaced and was in the lungs as opposed to the abdomen. The radiologist confirmed that the tube should not be used.

Despite this when a nurse later questioned if the feeds through the tube could be started the junior doctor present on the ward confirmed that they could as in his view the tube was appropriately placed.

Feeding was then started and in due course Brian’s condition deteriorated and upon further investigation it was discovered that the tube had been misplaced. Feeding was stopped immediately and the tube removed but by that stage the situation was irretrievable and Brian died three days later from pneumonia.

The hospital had carried out internal investigation and produced a report in which significant failings in care were accepted by the hospital and it was confirmed that such failings directly led to Brian’s death. The report noted that a Patient Safety Alert was issued by the National Patient Safety Agency (NPSA) in February 2005 following reports of patient deaths and harm caused by misplaced feeding tubes. In 2009 feeding into the lung from a missed placed NGT became a 'Never Event' and the hospital accepted that this tragedy should never have occurred.

The Coroner's Conclusion (Verdict)

After hearing evidence at the inquest on 21 of June 2021, Maidstone Coroner, Sonia Hayes stated that during Brian’s admission in hospital there were a number of missed opportunities to make basic checks that failed to identify and alert the misplacement of the tube that probably would have avoided the death.

The Coroner’s formal conclusion regarding the cause of death was that it was misadventure contributed to by neglect.

What Happens Next?

A civil claim will proceed against the hospital.