A pensioner died after a feeding tube was put into his lung instead of his stomach, an inquest heard.
Retired fitter Ernest Margerison, 86, died from pneumonia at the Maelor Hospital in Wrexham, 15 days after fracturing his hip in a fall at home on October 30, 2015.
At a hearing today John Gittins, coroner for North Wales East and Central, recorded a conclusion of misadventure.
But after learning of measures taken since the tragedy the coroner said he did not feel he needed to issue a Regulation 28 report to prevent future deaths.
“I am reassured by what I have heard,” he told the hearing at Ruthin.
Mr Margerison, a former semi-professional footballer from Dukesfield Drive, Buckley, underwent surgery at the hospital and according to his daughter, Carol Gregson, appeared to be making a good recovery.
He lost some movement in his right arm and although nothing was revealed by an X-ray, doctors believed he had suffered a minor stroke.
A nasogastric (NG) tube was inserted to boost his nutrition but on October 24 it had to be replaced after it had been pulled out.
Charlotte Pierce, the nurse who reinserted the tube, told the inquest Mr Margerison had helped her to insert it.
When she checked the aspiration reading to ensure the tube was reaching the stomach it was above the guideline level and although the level did drop Mrs Pierce asked for an X-ray which revealed the tube had been misplaced.
She told the inquest she could not understand how it happened as she had not been under any pressure when carrying it out and it was a procedure carried out two or three times every day on the ward.
Mrs Pierce now works in the emergency department where she no longer needs to insert NG tubes, but she told the inquest: “I wouldn’t touch an NG tube again after that.”
After concluding her evidence she told members of Mr Margerison’s family including his wife Patricia, that words could not express how she felt.
“I can only apologise for what happened,” she said.
Consultant physician Walee Sayed said the decision to feed Mr Margerison by tube was taken because he was not getting enough nutrition orally and he was making progress until the tube was replaced.
He told the hearing he did not know of any similar misplacements since Mr Margerison’s death.
The death was treated as a ‘never’ event by the Betsi Cadwaladr University Health Board and senior officials explained what measures had been taken as part of an action plan to prevent a repeat.
Immediately after the tragedy the PH level from the aspiration reading was lowered, staff training in risk awareness and procedures was stepped up and there was better liaison between nurses, medics and radiologists.
Paula Edwards, a nutrition nurse specialist, said there were now more formal systems for recording decision-making on the use of NG tubes and nurses were more able to challenge the decision of doctors.
The cause of death was given by pathologist Dr Andrew Dalton as pneumonia caused by a misplaced nasogastric tube, with the fracture a contributory factor.
Recording his conclusion, the coroner said: “I know it was classed as a ‘never’ event but sadly we recognise that occasionally things do go wrong. It should not have happened but it did.”
He praised the health board for taking such swift action to improve matters.