A Scottish health board has been fined £40,000 after a patient died when he was served food by hospital staff despite being deemed ‘nil by mouth’. His meal had been delivered to him by a student nurse on her first shift at the hospital, it was heard in court. 15 minutes later the patient was found to be unresponsive, with no pulse.
James South, 51, was admitted to the respiratory unit Raigmore Hospital on 27 December 2013 with several health complaints including anaemia and pneumonia. He remained in hospital on various wards for the next five weeks.
Inverness Sheriff Court heard that from 1 January 2014, naso-gastric feeding was commenced due to Mr South being sedated and intubated. With treatment continuing, he stabilised and his condition improved.
On 31 January 2014, he was transferred to a ward where he remained on naso-gastric feeding as staff felt swallowing was not safe. A few days later a review by the Speech and Language Therapy Team (SALT) advised Mr South was not able to undergo a formal swallow screen assessment and wrote in medical notes he was to be nil by mouth (NBM). A card was placed at the head of the bed.
The court was told that during the morning of the 6 February an auxiliary nurse who was unaware of Mr Ward’s nil by mouth status took his food order and Mr South himself had not indicated he was NBM.
At the lunchtime meal delivery a meal with Mr South’s name was collected and left for him by a student nurse on her first shift at Raigmore, who then left his room.
During the routine post-meal check, approximately 15 minutes after the meals were distributed, Mr South was found to be unresponsive with no pulse.
Nursing staff, medical staff and the patient’s consultant were alerted and attended. The consultant noted there was mashed potato at the side of Mr South’s face and within the mask which he had been wearing and which was lying by his side.
There was also a tray on the table which had a plate containing mashed potato and sausage. Also present was a bowl of soup and some ice cream, both of which appeared to be untouched.
HSE investigated the case and found NHS Highland had failed in its duty to ensure the health, safety and welfare of those not in its employment and did not take all reasonable steps to ensure that the risks to patients with special dietary requirements were managed.
Highland Health Board of Assynt House, Beechwood Park, Inverness pleaded guilty to a charge under section 3 (1) of the Health and Safety at Work etc. Act 1974.
After the hearing HSE inspector Niall Miller said: “The circumstances of this case were tragic and the death easily preventable. The failings demonstrate the need for effective communication and understanding in the health care environment and the need to appropriately manage the risks to patients with special requirements. “
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