Feeding tube in lung killed Donegal man Charles Ward
A nasogastric tube was responsible for the death of a patient when it was mistakenly placed in his lung by a nurse, an inquest has heard.
Charles Ward, 62, from County Donegal, was waiting for a liver transplant when the incident happened in January 2012.
A nasogastric tube is a feeding tube inserted through the nose, past the throat and into the stomach.
The Exeter inquest was told procedures at the Royal Devon and Exeter Hospital had since been changed.
Exeter and Greater Devon Coroner Dr Elizabeth Earland recorded a narrative verdict.
She said Mr Ward died from chemical pneumonitis caused by liquid feed going into his lung after the nasogastric tube was wrongly positioned.'Bit agitated'
Staff nurse Gavin Kelly, who inserted the tube, said although Mr Ward had "coughed and spluttered", he had "no reason to believe it was in the wrong place".
An acid pH test, which would have indicated the tube was in Mr Ward's lung and not his stomach, was not carried out correctly by the staff nurse, the inquest heard.
Mr Ward, who was born in Donegal, Ireland, but was living in Dawlish Warren, Devon, was fed by the tube for six hours, before collapsing in the early hours.
A crash team was called and he was taken into intensive care where he died a day later.
Nurse Paul Jenkins told the inquest Mr Ward was "a bit agitated" when the tube was inserted, but there was "no mention" of it being in the wrong place.
He said Okement ward, where Mr Ward was a patient, was always busy, but staff had not been rushed off their feet.
Medical expert Dr Jason Payne-James, a consultant forensic physician, said he did not believe Mr Kelly's actions constituted gross negligence.
The feeding tube used on Mr Ward was withdrawn from use after his death and a new model - with a tip which is easier to see on an X-ray - is now used at the hospital.
Solicitor Julie Ford, for the Royal Devon and Exeter Hospital NHS Foundation Trust, said the incident was "an unintended consequence of an intended action".
In a statement the trust said it "takes any incident of this nature extremely seriously and although they are very rare, they are acted on immediately, fully investigated and lessons identified so that the risks of them happening in future are minimised".
Em Wilkinson-Brice, Chief Nurse and Chief Operating Officer at the hospital, said: "Providing safe care to patients is our top priority and our clinical teams work to exceptionally high standards.
"It is important that staff feel comfortable in reporting any incidents and that we learn from these."
The trust said it had been in contact with Mr Ward's family "from the outset of our investigation into this incident to provide as much support and information as possible".