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A nurse broke down as he admitted making the fatal mistake of putting a feeding tube into a much-loved grandfather's lung instead of his stomach.
Jack Jolly suffered an “obliterated” right lung and died of pneumonia following the accident at Kent and Canterbury Hospital.
An inquest at Canterbury Magistrates' Court heard how nurse Jimmy Joseph, working alone, had battled to insert a gastric tube through Mr Jolly’s nose and down his throat before a family member offered to step in and help with the procedure.
Medics subsequently admitted that the tube had been incorrectly inserted and Mr Jolly had developed a serious infection.
Within two days the 88-year-old from Wingham was dead.
The hearing was told that Mr Jolly, a former lorry driver, milkman and site foreman, had suffered a serious stroke at his home in Oxenden Crescent on November 6, 2013.
He was taken by ambulance to Kent and Canterbury Hospital with anxious family members following by car.
Grandson Toby Ashmore told the hearing he was at his grandfather’s bedside on Kingston Ward on the first day. “I remember a nurse coming in and telling us what he was going to do,” he said.
"He tried getting it down his throat. It wasn’t very successful and we were trying to calm grandad down..." - Mr Jolly's grandson Toby Ashmore
“He explained to grandad that he’s got to swallow this tube and that it would help to get food into him.
"He tried getting it down his throat. It wasn’t very successful and we were trying to calm grandad down.
"The nurse was trying to hold this device on his chest – like a mini x-ray – to see if the tube was in the right place.
“The nurse didn’t seem to be able to do both at once. I asked him if he wanted me to hold the device and he said yes.”
Giving evidence, Mr Joseph, a nurse with the East Kent Hospitals University Trust since 2006, said: "Jack seemed to be distressed.
"Jack's grandson kindly helped me holding the receiver to his chest. I tried a few attempts [to get the tube down] but they failed.
"The tube was kinking. It's quite normal for patients to be distressed when we try to put the tube in.
"I did it again and it passed and he seemed to calm down. It did go down. I secured the tube with a plaster."
When shown a reading from a machine used to verify the position of the tube, Mr Joseph wept as he admitted: "Looking at it now, it shows it was not in Mr Jolly's stomach.
"I now think I misread it. I didn't have any doubts at the time."
The inquest was told that staff stopped the feed at about 9.30pm – three hours later – after Mr Jolly became “agitated”.
A different nurse, Mariamma Gaby, told the court a registrar later confirmed x-rays showed the tube was in the wrong place.
“It was in the right lung, it should be in the stomach,” she said. “It was obviously in the wrong place.”
By Saturday, November 9, Mr Jolly had developed an infection in his right lung caused by pneumonia and died that day.
Forensic pathologist Dr Peter Jerreat carried out a post-mortem examination on Mr Jolly.
His death was caused by a failure to recognise the tube had been misplaced..." - assistant coroner Christopher Morris
He told the court “cause of death was pneumonia as a result of a misplaced gastric tube”.
Summing up, assistant coroner for North East Kent Christopher Morris said Mr Joseph accepted he had put the tube in Mr Jolly's lung "in error".
What was harder to understand, he added, was why the mistake had not been noticed by the nurse, particularly as other medics had given evidence to say it should have been obvious."
But he ruled out a conclusion of neglect, saying it had been a "significant error of clinical judgement but not a gross failure to provide basic medical care".
Giving a narrative conclusion, he said: "Mr Jolly died following misplacement of a nasogastric tube into his lung. His death was caused by a failure to recognise the tube had been misplaced."
Mr Morris said he did not need to make any recommendations to prevent similar happening again because the trust had made a "key change" by having a second nurse verify tubes had been inserted correctly.
"It's quite clear the trust has taken Mr Jolly's death very seriously and has learned from it," he added.
Speaking after the inquest, Chris Bown, the interim chief executive of the East Kent Hospitals University NHS Foundation Trust, said: "We fully accept the conclusion of the coroner in this case.
"I unreservedly apologise to Mr Jolly's family. This is a critical area because of the importance of timely hydration and nutrition.
"I would like to reassure the public that we are continuously looking to improve safety in this area by introducing ways of minimising the impact of human factors.
"The nurse who performed the nasogastric tube placement is a competent and experienced registered nurse who, very unfortunately, made an error of judgment while placing the feeding tube."
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