Baby dies after air tube wrongly inserted into stomach instead of lungs

Posted 05/10/2008

A premature baby has died after a ventilation tube was mistakenly fed into her stomach rather than her lungs, an inquest has heard.

At the time, doctors at Great Western Hospital, Swindon, told the coroner that Mariyam Salam died from pneumonia related to her prematurity, in February 2004. In July 2004, a paediatrician looked at the X-rays and realised the tube had been put into her oesophagus. She had survived for eight days after she was born four months early.

Mariyam was born on 21 February 2004, weighing 1lb 10oz (660g), after just 24 weeks and five days’ gestation, the court was told. No post-mortem examination was carried out at the time, at her parents’ request, citing cultural reasons.

The coroner recorded a narrative verdict saying the cause of death was acute respiratory failure. The tube had been inserted in the wrong place in circumstances linked to her prematurity, he said.

In evidence at Swindon Coroner’s Court, Dr Helen Price, a consultant paediatrician who was on duty when Mariyam died, said that after repeated attempts to insert the tube, she still could not hear air going into the baby’s lungs.

‘The answer in retrospect was that the tube was in the wrong place,’ she said.

‘At the time I read the X-ray as showing that there was pneumonia. I thought the baby had collapsed and was very ill with a chest infection. Nobody else thought we were seeing anything different. I had never seen this before.’

Dr Price told the inquest attempts were made to transfer the baby to specialist units at Oxford or Bristol but there were no spaces available.

The inquest heard the tube remained in the oesophagus for nine hours leading up to Mariyam’s death. Two sets of X-rays were done but the error was not spotted.

In a statement after the verdict, Swindon & Marlborough NHS Trust, said: ‘We are very sorry for the loss of baby Mariyam Salam.

‘Measures have been taken and are in place to make sure such a tragedy doesn’t happen at the Great Western Hospital again.’

‘Sadly we often see one mistake compounded by others,’ says Sandra Patton, a member of Ashtons Legal’s specialist clinical negligence team.

‘It seems that one clinician assumes that what has already been done is effective and working. Occasionally that isn’t the case, but unless the clinician takes an overview of the situation and is prepared to review what treatment the patient has already had, then these tragedies will continue to occur.’