Sheriff clears hospital staff and questions need for fatal accident inquiry into Cowdenbeath man's death
The death of a Fife man whose bowel was perforated by a gastric feeding tube could not have been prevented, a sheriff has ruled.
- By Claire Warrender
- Published in the Courier : 10.01.12
- Published online : 10.01.12 @ 12.01pm
Sheriff Ian Dunbar said there were ''no reasonable precautions'' whereby the death of John Johnston might have been avoided.
Mr Johnston (79) died in Queen Margaret Hospital, Dunfermline, in December 2009, after months of ill health.
The cause of the Cowdenbeath man's death was given as sepsis, infection of a total parenteral nutrition line and complications of the insertion of a feeding tube known as a PEG, pulmonary fibrosis and coronary artery disease.
Following a fatal accident inquiry at the beginning of December, Sheriff Dunbar has also found there were no defects in any system of work which contributed to Mr Johnston's death. He added there were no other circumstances relevant to the death.
However, the sheriff questioned the need for an inquiry given the wealth of medical evidence available to the Crown, and said the cost to the public must have been ''significant''.
He said that of 1,957 pages of documentary evidence produced by the Crown, fewer than 100 pages were actually referred to.
''I would ask if this inquiry was necessary given both the purposes of an inquiry in terms of the Act and the whole medical picture including the expert evidence available to the Crown, presumably before any decision was taken to hold an inquiry,'' Sheriff Dunbar said.
''I would also ask why it was thought either necessary or appropriate to lodge so many pages of productions, most of which had no bearing on the inquiry.
''The cost of reproduction alone must have been significant, never mind the cost of time to the public purse.''
The sheriff described Mr Johnston, a former miner, as ''not a well man'' and said he had been unwell for a number of years. He had fibrosis of the lungs, type 2 diabetes, he had had a series of mini strokes and in 2007 was diagnosed with Barrett's Oesophagus, a condition which made swallowing hard.
A gastric feeding tube was inserted in what was regarded as ''a normal and relatively simple long-term option to promote and support nutrition''.
However, instead of being inserted into his stomach, the tube perforated Mr Johnston's bowel — something which was not discovered for two years, despite complaints about pain and discharge from the PEG site. Once the PEG was removed, it left an opening from the colon to the abdominal wall which continued to drain faecal fluid.
Mr Johnston became more unwell and developed a fever. The following day he was described as being in septic shock and having end stage pulmonary fibrosis and he died three days later.
The sheriff said that while there was a chain of consequences between the PEG insertion and the death, it was not direct.
''All the doctors said that perforation of the bowel was a rare but recognised complication of PEG insertion,'' he said. ''It has to be accepted that the PEG insertion in 2007 went wrong. What went wrong is a known complication of the procedure.
''Once it was discovered then the medical staff seems to have done everything they could and there was no professional criticism of what they did. By that time it seems clear there was nothing that the doctors could do for him.''
05.11pm - 10.01.2012 David - n/a, n/a Report This
Whilst the Sheriff would have more information available to him, as reported above the issue was not picked-up for two years yet was a known complication. The patient lost and his overall health may have been consequential of having worked on heating and powering the nation.
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