Settlement agreed after fatal nephrostomy tube error

Ali Masterson, Trainee Legal Executive with the Medical Negligence Team, has obtained a settlement for the family of Mrs G, who sadly died following a failure to remove a cap from a nephrostomy tube, which was not identified for 3 days.

Mrs G was admitted to the Hospital suffering from a severe UTI complicated by a history of metastatic and progressive transitional cell carcinoma bladder cancer. She was treated for the UTI with the intention to discharge home; however, her routine replacement of her nephrostomy tubes was due, and it was decided to keep her in for the tube exchange before discharge home.

The tubes were replaced; however, the cap from one of the tubes was not removed, and this was not noticed for a further 3 days until Mrs G was reviewed by a specialist doctor. By this point, Mrs G had begun to develop sepsis and continued to deteriorate, sadly dying 7 days later.

The Trust undertook an internal investigation and, amongst other issues, identified that the nephrostomy had not been removed and that this had not been picked up for 3 days. A Letter of Claim was sent to the Trust, which resulted in admissions being made with regard to breach and limited causation. Ms Masterson was able to discuss the settlement with the NHSR and bring the matter to a quick resolution.

Ms Masterson says, “The Trust identified and admitted issues with the care provided to Mrs G, which the family said clearly contributed to the tragic outcome in this case. Following their internal investigation, the Trust have put measures in place to reduce the risk of this happening again. Of particular importance to the family was recognition that failure to remove the tube cap and the delay in recognising this, which caused sepsis to develop, contributed to their mother’s death. Thanks to my counterpart at the NHSR, we were able to discuss and resolve this matter quickly to avoid prolonging the family’s grief.”

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