Decision Report 201809447

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A). Mr A was admitted to hospital after he attended A&E complaining of abdominal pain with a background of hiatus hernia (where part of the stomach pushes up into the lower chest). Mr A had a nasogastric tube (where a tube is placed through the nose into the stomach) inserted to decompress the hiatus hernia, however on one occasion it fell out and a number attempts had to be made before it was reinserted. During this procedure, Mr A suffered a cardiac arrest and died.

Mrs C complained that the board inappropriately handled the insertion of his nasogastric tube and raised concerns that it may have caused Mr A's cardiac arrest. Mrs C also complained that insufficient attempts were made to resuscitate Mr A when he suffered cardiac arrest.

The board explained that nursing staff escalated the procedure for passing the nasogastric tube appropriately and that Mr A arrested before any further escalation could happen. The board also explained that Mr A’s cardiac rhythm was asystole (unshockable) therefore attempts to prolong resuscitation would be ineffective.

We took independent advice from a consultant general surgeon and from a consultant in acute medicine. We found that reasonable action was taken by the nursing staff in escalating the reinsertion of the nasogastric tube and there was no evidence that the procedure was inappropriately handled. We also found that the decision to stop resuscitation was made in consultation with the clinical staff present and the decision was reasonable in light of his additional conditions and the fact that his heart rhythm was asystole. Therefore, we did not uphold Mrs C's complaints.