Retired firefighter died after feeding tube inserted into his lung instead of stomach

-Credit: (Image: LeighDay)
-Credit: (Image: LeighDay)


A 'pillar of the community' retired firefighter and councillor died from pneumonia after a feeding tube inserted into his lung instead of his stomach wasn't spotted on an X-ray check by an untrained junior doctor, an inquest heard.

The doctor's error led to up to 200ml of fluid food being pumped into Terence Butler's lung for 15 minutes. He died four weeks later. A coroner concluded Mr Butler died 'as a consequence of misadventure contributed to by neglect' after an inquest hearing on Friday. His family, speaking afterwards, said he served as a firefighter for 25 years, saving lives in the process.

The so-called 'never event' at the Royal Albert Edward Infirmary in Wigan in January, 2024, led to a deterioration in Mr Butler's condition and he died on February 16 this year, aged 83. The NHS class 'never events' as incidents that shouldn't ever happen in a medical setting.

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At the inquest at Bolton Coroner's Court, his daughter Elizabeth Harrison said the family believe the 'shocking incident' contributed to his premature death. "The family are struggling to come to terms with his death," she said. "The family feel that he was suddenly taken from us."

The hospital trust apologised and admitted 'on this occasion, standards of care were not met, as a result of which we failed the patient and the family'.

Mr Butler was born in Wigan and worked in a colliery before becoming a firefighter. He retired in the 1990s due to an injury and became a councillor in Wigan.

Coroner Alexander Frodsham said an X-ray of the tube to check if it was in Mr Butler's stomach was 'erroneously interpreted' by a junior doctor who had not received 'adequate training'. The inquest heard the doctor, who wasn't named, didn't even know the training was available.

Mr Butler was treated at the Royal Albert Edward Infirmary -Credit:Manchester Evening News
Mr Butler was treated at the Royal Albert Edward Infirmary -Credit:Manchester Evening News

It's not known whether he is facing any disciplinary proceedings, the inquest heard.

Nicola Heath, head of governance at the hospital, said an investigation was held and she had spoken to the junior doctor involved. Ms Heath said the investigation identified that the medic involved had not been trained to confirm the correct placement of a nasogastric tube, was not aware training was available and had wrongly interpreted the X-ray image.

Mr Butler was admitted to hospital after attending the accident and emergency department on December 29, 2023, with a fever caused by a catheter-related urinary tract infection. He had to be fed by a nasogastric tube. The inquest heard the tube was inserted and a routine chest X-ray was performed to check its position.

But, the coroner was told, the X-ray was misinterpreted and the junior doctor thought the tube was in the right position. The tube had been inserted into Mr Butler's left lung instead of into his stomach, but it was only discovered after 15 minutes when Mr Butler began to struggle to breathe and complain of chest pain.

He developed pneumonia and died four weeks later.

The inquest heard there were two further incidents involving nasogastric tubes at the hospital – in 2017, when the medic who interpreted the X-ray had not been trained, and in 2019, when the doctor interpreted the image in error. After the 2017 incident, nasogastric tube placement training became mandatory for junior doctors, but the medic in Mr Butler’s case, “slipped through the net” as he was classed as a “clinical fellow” rather than a junior doctor.

An inquest into Mr Butler's death was held at Bolton Coroners Court -Credit:MEN MEDIA
An inquest into Mr Butler's death was held at Bolton Coroners Court -Credit:MEN MEDIA

Following the inquest, Mr Butler's family said in a statement: "Terry was a much-loved husband, father, grandfather and great-grandfather, who had served in the fire brigade for 25 years. He saved many lives as a firefighter and survived a number of very dangerous situations.

"In retirement he served as a councillor and as a school governor. As a family we are devastated at his loss. We feel it was not dad's time to die and had it not been for this incident he would now be at home enjoying life with his family. We have some wonderful memories of dad and he will always be in our hearts."

Stephen Jones, law firm Leigh Day's clinical negligence team partner, said Terry's death was 'completely avoidable'.

He said: "Feeding a patient through a misplaced nasogastric tube should simply never happen. The Trust's internal procedures provided that a doctor requesting the X-ray must have had specific training in chest X-ray interpretation of nasogastric tube placement. However in Terry's case, the X-ray review was undertaken by a doctor who not only had not completed that training, but had not been made aware that this training was available. This was a systemic breakdown that tragically led to his death."

Professor Sanjay Arya, Medical Director at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust., said: "We extend our deepest sympathies and condolences to Mr Butler family and friends. We always try to do our best for our patients but on this occasion, standards of care were not met, as a result of which we failed the patient and the family, for which we are truly sorry.

"Following this incident, a thorough investigation was conducted and reviewed, and a comprehensive action plan was implemented. We also acknowledge the need for continuous improvement and are fully committed to learning from every aspect of the care provided. The Trust remains dedicated to delivering the highest standard of care and the safety and well-being of our patients will always be our top priority."