Homerton University Hospital tube put in grandmother's lung
An elderly woman died partly due to the "misplacement" of a feeding tube into her lung in a hospital error, a coroner has said.
Andriana Georgiou, an 84-year-old grandmother, contracted pneumonia and died 11 days after the mistake in December 2012.
She was being treated at the Homerton University Hospital in east London.
Mary Hassell, senior coroner for inner London north, recorded the narrative verdict at Poplar Coroner's Court.
Ms Georgiou died from a combination of natural disease, stroke and the tube "misplacement", she said.
Finnish-trained consultant Dr Kari Saastamoinen made an "error" in using the "whoosh" test to wrongly verify that the tube was correctly inserted, Ms Hassell said.
This was despite the test - where air flow is listened to in the tube to check whether it is in the right place - being the subject of three patient safety alerts since 2005, she said.
"The senior nurse asked the doctor for a check X-ray but he opted instead to perform a whoosh test and he was then satisfied that the tube was in the right place - and feeding began," Ms Hassell said.
"It was not," she added. "A patient safety alert on February 21, 2005, and two subsequent alerts directed that the practice of using a whoosh test to check the position of a naso-gastric tube must cease immediately."
The error occurred despite there being "good" systems in place at the hospital, Ms Hassell said.
Dr Saastamoinen told the inquest he had learned the "whoosh test" at medical school in Finland and had used it on several occasions in that country without problems.
He said he had not been aware at the time that it was trust policy for a patient to go for a chest X-ray where a litmus test indicated that there could be a problem.
Dr John Coakley, the hospital's medical director, said: "I extend my condolences to Mrs Georgiou's family - I met many of her family on the intensive care unit and apologised for this incident."