A ‘Never Event’ and the chain of the blame

This is an example of worst case scenario thinking. It is an entirely fictional case. I have used the same approach that I use in my medical fiction, working out how, within the boundaries of plausibility afforded by standard clinical processes and environments, a particular error might occur. Perhaps this accident happened somewhere, sometime…I don’t know.

This exercise in imagination is intended to show how difficult it is determine where blame lies. Few medical mistakes, in my experience, occur because one person made one mistake. There is often a ‘series of unfortunate events’, each one of which could, perhaps should, have been recognised and reversed before the next occurred. As I read about the ‘duty of candour’ in the Francis report on Mid-Staffs, and read about Jeremy Hunt’s response to it on behalf of the government, I reflected that each time a patient is harmed it will become necessary for hospital Trusts to make a judgement as to whether the incident requires a patient or family to be contacted (whether or not they have complained). It is clear now that there will be no legal compunction for individual healthcare professionals to admit to and communicate these errors, but organisations as a whole (embodied by ‘the board’) will have to recognise and act on that duty. It is not clear to me how this will work. Organisations are collections of individuals, and for the truth about avoidable harms to rise to the top those involved on the shop floor will have to be honest and forthcoming.

I wondered how individuals would respond in a ‘harm’ situation. I tried to imagined a scenario that should never happen, but did. Never Events are medical mistakes that the NHS Litigation Authority (NHSLA) have deemed avoidable and, to be blunt, indefensible. They are, ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.’ Never Events are reported annualy, and spikes in their frequency tend to be picked up by the press (as in Derriford, Plymouth in March 2013).

One Never Event is when liquid food is poured down a nasogastric feeding tube (NGT) that has been accidentally inserted into a lung. If food is dripped into such a misplaced tube the patient will literally begin to drown, and the consequences of this range from becoming transiently short of oxygen, to developing pneumonia, requiring mechanical ventilation or dying. Hospitals have protocols that are designed to ensure that this never happens, and the NHSLA has published algorithms to minimise the risk.

Here then is a reconstruction of how this Never Event might happen; as you read it, ask yourself who is to blame and how it might be communicated to the family.

 -/-

The date was 2rd February 2013 (a Saturday).

Mr Mohammad Ghazi was 78 years old, and had been admitted one week previously with a stroke which affected his ability to swallow. He was fed via a NGT, but on two previous occasions he had accidentally dislodged the tube.

Dr Martin Simpson didn’t know Mr Ghazi. He was asked to get involved at 5.30pm on the Saturday in question. The nurse in charge of the ward, Susan, called him to report that Mr Ghazi had pulled out his latest NG tube in the morning, and that she had inserted another at 3pm. However she could not get a reliable pH (gastric acidity) reading from the aspirate, which she attributed to him having residual feed in the stomach and the fact he was on high dose acid supressants. Without the acidity test she could not confirm that the tube was actually in the stomach, ans protocol dictated that a chest x-xray (CXR) was required. Martin agreed to arrange the CXR and promised to look at it before he finished his shift at 9pm. He asked Susan to bleep him when the x-ray had been done; he was going to be busy clerking new patients in A&E, as the registrar had requested that he help the admitting team during the traditional early evening rush. Martin sent an electronic x-ray request through and forgot about it. Someone would let him know when the x-ray was ready.

At 8.30 pm Susan walked onto the ward having popped out to pick up a drug from pharmacy for another patient. She held the door open for the porter who was bringing Mr Ghazi back from the x-ray department. She helped the porter wheel Mr Ghazi’s bed into the empty bay and, noting the time, went to bleep Martin. He answered promptly, logged on to the x-ray programme on a computer in A&E, scanned along the list of Mr Ghazi’s x-rays, clicked onto the one dated 3/2/2013 and saw that the tube position was perfect. The tip of the tube lay well below the diaphragm, it crossed the edge of the main airway, it was definitely in the stomach. He called the ward, Susan answered, and Martin confirmed that he was happy for her to commence the feed that night. Martin left at 9.30pm. Susan left at 10pm, leaving it to the next shift to turn the feed on.

At 11pm the ward sister on the night shift, Mary, answered the phone. It was the x-ray department, ringing to see if Mr Ghazi was available to come for his x-ray. Mary answered that he had already had it. No, said the radiographer, the request hadn’t been checked off. ‘Why was in he taken down to the department earlier then?’ asked Mary. The radiographer checked the system – oh yes, that had been for an ultrasound which had been booked a couple of days ago; the on-call radiologist had decided to do it that evening in order to clear the backlog. He hadn’t yet had the x-ray for the new NG tube.

Mary ran to the bedside. Liquid food was being dripped into the tube. Mr Ghazi was breathing badly. She stopped the feed immediately and called the medical team. The night doctor came to the ward and logged onto the x-ray programme. The x-ray that Martin had looked at was the wrong one – the right date, but the wrong time, taken in the very early hours of the same day to check the previous NG tube, the one that had been removed.

Mr Ghazi developed pneumonia, deteriorated and died a week later.

Investigation – assumptions and facts

The investigation showed that Martin had indeed looked at the wrong x-ray, and that the right x-ray had never been done. Susan was mistaken in telling Martin that the x-ray had been done – when she saw Mr Ghazi returning to the ward with the porter she had assumed, erroneously, that he had just had his x-ray. That assumption went unchallenged, and when Martin saw that an x-ray had been performed on the relevent date he assumed this was the new one. He did not check the time.

When the x-ray was eventually performed it showed that the new NG tube was in the right lung, and the lung was already turning white, filling with liquid feed.

Testimonies

Susan: I saw him being wheeled in. It was natural to assume he was coming back from his chest x-ray. I didn’t even know he was booked for an ultrasound. He had come to our ward the day before, it must have been booked when he was on the other ward. The timing fitted. Do I think what happened is my fault? No, actually. It wasn’t me who checked the x-ray…

Martin: I’d never met him. I didn’t know him, didn’t know he’d had an NG tube down just the day before, that it had been x-rayed overnight, at 2 in the morning! Susan…and I’m not blaming her…told me that he had come back from his x-ray. I saw on the computer that there was an x-ray taken on the day in question, it looked fine. Why didn’t I check the time? I can make excuses…I was rushing, but aren’t we all, all the time. I was clerking, when actually I was supposed to be on ward cover…but if I’d been doing that I would have been just a busy probably. You know, I can’t see how this could have been avoided. Not unless there was some way of linking the x-ray to the specific NG tube insertion. How could you do that?

Susan: His son came in, sat with him as he died. We didn’t send him to intensive care, he would never have survived on a ventilator. I explained how food had got into his lung, and he didn’t asl me how, or why… he didn’t assume a mistake had been made. And it wasn’t the right time to go into all the details then and there. He had to have some time to grieve…I think that’s reasonable. We didn’t hide anything.

Mary: I felt awful. I set up the feed pump. As soon as I turned it on the feed began to drip into his lung. I did that, I can’t get way from that. But should I, personally, have checked the tube was correctly sited? I don’t think so. I’m not trained to look at x-rays. Martin, the doctor, told me it was fine. I can’t do more than that…can I?

Martin: Because he wasn’t actually my patient I didn’t find out until the following Wednesday. The registrar on the stroke team came to find me, and let me know. She told me there was bound to be a complaint. I asked her straight away if the family had been told. I volunteered to tell them…but she said it would wait, and that their team would deal with it. But she did advise me to write everything down, all the details, in case I ended up giving evidence to the coroner. I went home and typed up a narrative… I still have it.

The clinical director: The simplest, harshest analysis is that Martin was negligent in not confirming that the x-ray he saw related to the new NG tube. If he had taken note of the time on the screen he would have realised immediately. But I’m sympathetic to his explanation. There was duplication. Two x-rays requested in a short period of time, less than 24 hours. Perhaps, just as we highlight and take special precautions if there are two patients with the same surname on a ward, we should highlight if two tests are arranged for the same patient…to ensure the right one is looked at. This terrible event has exposed a weakness in the system. I have never heard this happen before, anywhere. So it’s hard to say to the family, yes, we made a terrible mistake and did badly by your husband and father…we did, of course, but I cannot see where we could have done better on the night in question. The mistake was there waiting to be made, all the time. It could have been anyone who made it. We now need to look at ways of making sure it never happens again.

The Board (a representative): We were all agreed, we needed to tell the family. By the time we discussed it the initial investigations had been completed, and it became clear that the family had no idea that a mistake had been made. That made it more difficult than if they had been told straight away. It came as a complete and utter surprise to them, to the son anyway…he was the main contact. But even then there was no anger. It won’t always be like that obviously…but this family were philosophical, and took the view, very reasonably, that medical interventions come with inherent risks. We do not necessarily take that view – feeding through a tube should not be risky. That’s why it’s a ‘never event’. It is avoidable.

The family (his son): The Trust were candid with us. They called me, invited me in for an interview, and the consultant explained what had happened. Although I had never heard of Never Events, I realised once they admitted to us that it was food in the lung that killed him that this should never have happened. It’s basic. But I read their investigation, and I can’t see who or what to blame. The poor guy who saw the wrong x-ray, his is probably the greatest responsibility. But if I blame anyone I blame the Trust…did it go over how crucial it is to double check the time, did it train its junior doctors for that situation? Perhaps they should train nurses to read these x-rays, I don’t know. You might think that’s an over reaction, but this was supposed to be a ‘never’ event…and it happened. By definition therefore, inadequate preparations had been made. They hadn’t thought it through…not until my father died.

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