Coroner rules that neglect contributed to death of patient

Solicitors at law firm Leigh Day are pursuing legal action against a Harrow hospital after an 85 year old woman died after failures in her treatment.

In February 2018, 85 year old Puspa Monji from Brent was admitted to Northwick Park Hospital for the repair of an abdominal hernia. During her recovery in hospital, concerns were raised over her ability to swallow food safely and she was fitted with a tube so that food could be administered directly to her stomach. 

Due to the risk of the tube being threaded into a patient’s lung instead of their stomach, it is standard practice across hospitals to confirm the positioning of the tube before commencing any feeding. This is done by carrying out a test to check for stomach acidity and/or carrying out an x-ray (sometimes both).

On 7 March, Puspa had a new tube fitted and was sent for a routine x-ray to check the position. The results of the x-ray were not reported until some three hours later and showed that the tube was correctly positioned in the stomach. However, in the intervening time, the original tube had been removed by one of the nurses and another fitted, meaning that the position of the new tube needed to be confirmed.

A further x-ray was taken later that evening and was reported in the early hours of the next morning, 8 March. The tube was seen to be in Puspa’s lung and the radiologist put a note on his report to advise that this was unsafe and should be removed immediately. He also telephoned and spoke to someone, thought to be a nurse on Puspa’s ward, with this advice. Unfortunately, however, for reasons that are not known, the tube was not removed at that time.

The radiologist had also noticed that the time stamp on the first x-ray was incorrect, so he issued an addendum to correct this. This addendum meant that the report relating to the first x-ray appeared at the top of the imaging system, rather than the last x-ray.

During the morning ward round on 8 March, Puspa’s doctor reviewed the x-ray report to confirm that the tube was safely in the stomach and that feeds could be put through the tube. The doctor looked at the report of the image at the top of the imaging system, erroneously assuming it to be the most recent image, and concluded that the tube was safe to use.

Meanwhile, Puspa’s nurse had tried to obtain a pH sample to test for stomach acidity, but had been unable to get one for technical reasons. The doctor, however, instructed the nurse that this was not necessary as he thought the x-ray showed that the tube was in a safe position. He therefore instructed the nurse to commence feeding.

Soon after the feeding started, Puspa began to complain of increasing pain. Although initially dismissing the pain as constipation, the nurses later stopped the feed and the doctor requested a further x-ray. This x-ray confirmed that the tube was in the wrong positon but, by this time, about 200ml of feed had been delivered into Puspa’s lung.

Sadly, Puspa developed aspiration pneumonia caused by the feed and there was nothing that could be done to save her. She was referred to a palliative care team and passed away a couple of days later. 

The coroner was informed and an inquest was heard in August 2018.

After hearing the evidence at the inquest, Senior Coroner Andrew Walker concluded that Puspa had died due to “consequences of medical treatment contributed to by neglect”. He added that “there were many opportunities to prevent Mrs Monji’s death” and raised concerns that a number of failures coincided to contribute to the death, including the lack of labelling on the tubes and the failure of the hospital staff to follow its own policies regarding the insertion of such tubes and the assessment of tube positioning.

The Trust has admitted liability for Puspa’s death and has confirmed that measures are being taken to minimise the risk of future deaths of this type.

Puspa’s family has instructed Sarah Campbell and Michael Roberts from Leigh Day’s clinical negligence Department to pursue a legal claim and discussions are taking place with the Trust’s lawyers.

Puspa’s grandson, Mr Kishan Parshotam, said on behalf of his family: “Knowing that my Grandmother’s death was preventable is extremely tough for us all. Puspa, or Ma as we fondly called her, was an incredible Mother and Grandmother, who had a challenging life. To have lost her to mistakes and negligence is devastating, which is why we have instructed Leigh Day and commenced this course of action to try to ensure no other family has to endure what we have had to in dealing with Ma’s death.” 

Medical negligence solicitor Michael Roberts commented, “Although nothing can be done to reverse the tragic events of this case, the family take solace from the outcome of the inquest and hope that lessons have been learnt so that others will not have to suffer as Puspa did.”