Nurses unaware of danger - inquest told

Nurses who treated a retired retail manager who died after a feeding tube was placed in his lung were not aware of crucial clinical guidance issued two years earlier, an inquest heard.

Ronald Kemble, aged 81, of Acorn Road, Halesowen, died at Russells Hall Hospital in December 2007. He had been rushed to the hospital in Dudley after his daughter noticed that he was struggling to breathe.

This had happened when she visited him at Warrens Hall Nursing Home in Tividale.

Smethwick Coroner's Court heard Mr Kemble's condition had deteriorated after a feeding tube was replaced by community nurse Paula Harris. Home Office pathologist Dr Kenneth Shorrock told the hearing the tube had been incorrectly inserted into Mr Kemble's right lung rather than his stomach.

Called to give evidence by Black Country coroner Mr Robin Balmain, Miss Harris said the home's then deputy manager Naomi Jones had asked her to insert a new tube on the afternoon of November 26.

After placing the tube Miss Harris asked her colleague to check the tube and both carried out a so-called "whoosh-test".

The court heard under the test, air is pumped down the feeding tube while the nurse listens for a bubbling sound in the stomach to indicate the tube has been placed correctly.

Mr Balmain read a passage from a report published in 2005 which stated use of the "whoosh test" should "cease immediately" as it could produce "false positive results".

When asked whether they were aware of the report, both Miss Harris and Mrs Jones replied: "No".

Earlier Dr Shorrock had told the jury Mr Kemble "would not have died when he did" if the feeding tube had not been incorrectly inserted into his right lung.

A post mortem examination found Mr Kemble's lungs were much heavier than a normal weight.

The inquest continues.