Hospital apologises after feeding tube error leads to death of man with Down syndrome

Seán McCárthaigh

A verdict of medical misadventure has been recorded in the death in hospital of a man with Down syndrome after feed from a displaced nasogastric tube entered his lung.

Michael O’Connor (65) of Upper Glenageary Road, Glenageary, Co Dublin, died while being treated for pneumonia, which he had developed as a result of a spinal condition, at St Vincent’s University Hospital in Dublin on August 25th, 2023.

The hospital’s director of nursing, Ann Flynn, issued an apology to O’Connor’s family at an inquest into his death at Dublin District Coroner’s Court on Wednesday and expressed “sincere regret” for the incident which had resulted in his death.

A consultant in infectious diseases at St Vincent’s, Patrick Mallon, said what happened was “a very rare and extreme set of circumstances” and the only such incident that he had experienced in his career of over 25 years.

Staff nurse Eliezar Obmerga, who provided care for the patient from the evening of August 24th 2023, gave evidence that he checked O’Connor’s vital signs at 8:16pm.

Although his oxygen saturation level was in the acceptable range, Obmerga said he felt something was wrong with the patient but was not sure what the exact issue was.

The nurse said he checked the patient again at 11:20pm when an early warning score, which is used to identify clinically deteriorating patients, had increased.

Obmerga said he only called the on-call medical registrar to attend to the patient after O’Connor’s saturation levels had fallen outside the acceptable range and the early warning score had increased further the following morning at 1:45am.

The inquest heard a chest x-ray ordered by the registrar confirmed that the patient’s NG tube was not in the proper place.

Obmerga said he was confident about the quality of care he had provided to O’Connor, whom he said he had monitored “as if he was part of my family.”

In reply to questions from the coroner, Myra Cullinane, the nurse said he had decided to check the patient more frequently when he felt there was something wrong, although he accepted that such monitoring was not recorded in the medical notes.

Obmerga said he had not escalated the care by calling a doctor as O’Connor’s oxygen saturation levels had remained within the acceptable range and he had appeared “very comfortable.”

He said he was satisfied the NG tube had been “intact” whenever he had checked the equipment.

Under questioning by counsel for the deceased’s family, Esther Earley, Obmerga accepted that the only entry in the patient’s medical notes about the NG tube was from 12:10pm on August 24th, 2023, when it had been changed and feed started by the day nurse.

The nurse told counsel for St Vincent’s, Brian Sugrue, that the only visible sign of O’Connor’s condition deteriorating was his breathing becoming faster at around 1:45am.

Another staff nurse, Chelsea Atienza, said O’Connor had been classified as a high-risk patient for having an NG tube as he had a history of pulling out intravenous lines and required 24/7 monitoring by a healthcare assistant.

Prof Mallon gave evidence that O’Connor had been admitted to St Vincent’s on July 24th, 2023, with a complaint about pain in his lower back and an x-ray confirmed he had sustained a crush fracture on his spine.

The inquest heard he was transferred to the hospital’s intensive care unit on August 11th, 2023, after his condition deteriorated.

However, he recovered sufficiently to be transferred back to a general ward six days later.

Prof Mallon said a NG tube was put in place on August 18th, 2023, as it was not safe for the patient to have any oral intake due to the high risk of aspiration.

It was replaced the following morning after O’Connor had pulled out the tube.

His condition subsequently deteriorated, although X-rays had confirmed that the NG tube had remained in a satisfactory position until August 25th, 2023.

Prof Mallon said he believed O’Connor was “critically unwell” and “very brittle” throughout his hospital stay, although doctors had “pursued an active management plan to reverse his illnesses.”

In reply to questions from the coroner, Prof Mallon said NG tubes were common but normally reserved for critically ill patients.

He said there were “lots of different ways” in which a tube could become displaced, but the effect of feed entering the lungs would be “absolutely devastating.”

Prof Mallon said he did not believe O’Connor would have died when he did but for aspirating feed into his lung.

Flynn told the hearing that an internal review of the case had found a lack of adherence to the hospital’s policy for the insertion and maintenance of NG tubes as well as a lack of adherence to guidelines about the Irish National Early Warning System.

The director of nursing said the review had made several recommendations, including having an audit to ensure compliance with NG tube records and holding refresher training for the management of NG tubes at the ward level.

Flynn said it was also recommended that an acceptable early warning score be documented in a patient’s medical chart and that nurses were to escalate care if the information was missing.

She told the inquest that the hospital had subsequently revised its NG tube checklist to include a requirement for a tube to be checked every four hours.

The witness said refresher training was ongoing, while the management of NG tubes had also been incorporated into training programmes for undergraduate and foreign-trained nurses.

Flynn said the hospital had also created a new role for a clinical nurse manager to focus specifically on the training, awareness and monitoring compliance by nursing staff of escalation processes, response times and documentation standards.

In addition, she said critical care outreach advanced nurse practitioners have been appointed to support bedside nursing staff in the management of deteriorating patients.

Flynn said a digital early warning score system had been introduced in 2025 which had replaced the older paper-based monitoring system.

Returning a verdict of medical misadventure, Dr Cullinane offered her condolences to O’Connor’s brother, David and his wife, Becky, who were accompanied by their solicitor, Piarais Neary.

The deceased’s brother, Paul O’Connor, gave evidence via videolink from Australia of formally identifying his brother’s body to gardaí.

On behalf of St Vincent’s, Sugrue said he hoped O’Connor’s family might get some comfort from the steps being put in place by the hospital to avoid a similar incident in future.