Sunday, October 11, 2009

Another disabled person injured and lucky to be alive this time a 7yr old

They blamed this mistake which will impact on this child for the rest of his life on the "fact" that "the lamp next to Francis bed, used to check the colour on the litmus paper, was not working, making the room dim and difficult for staff to determine if the tube had touched stomach acid or lung secretions. This is Westmead Children's Hospital - the major children's hospital in NSW and a teaching hospital. Its got to stop surely and they have got to be made accountable.

"Hospital bungle leaves family seething
October 10, 2009

THE family of a boy who almost died after a ''breathtakingly basic'' hospital bungle nine months ago is still waiting for a written apology and a change in policy to prevent other children suffering the same fate.

Francis Wilks-Tansley will be fed through a hole in his stomach for the rest of his life and is unable to breathe properly after a feeding tube was inserted into his lungs - and not detected for 36 hours.

During that time the seven-year-old, admitted to The Children's Hospital at Westmead for seizures, was given water and six medications through the tube, causing him to develop a life-threatening pneumothorax, where air gets trapped in the cavity around the lungs, and his right lung to collapse.

One of the drugs, sodium valproate, causes severe chemical burns to lung tissue.

Up to six staff tended to Francis, who was born partially blind, deaf and with limited voluntary movement, over several shifts before the error was discovered, despite repeated calls from his mother, Sarah Wilks, that he was in respiratory distress. A chest drain was then inserted for 17 days to remove the fluid in his lungs.

''He was in agony, in extreme pain,'' she said yesterday.

One staff member, who did not want to be named, described the mistake as ''breathtakingly basic''. Staff must draw out some contents of feeding tubes as soon as they are inserted to test for the presence of stomach acid. A drop is placed on litmus paper, which turns a vivid pink if stomach acid is present. A chest X-ray can also be used to confirm the tube's placement, particularly in heavily sedated or unconscious children.

But Dr Wilks, who has a PhD in biology, said the lamp next to Francis' bed, used to check the colour on the litmus paper, was not working, making the room dim and difficult for staff to determine if the tube had touched stomach acid or lung secretions.

A case review carried out by the hospital found there had been three attempts to insert the tube, and its blood-stained contents had turned the litmus paper pink, leading staff to believe it had been placed correctly. But it also said difficult or repeated attempts should alert staff to the need for an X-ray to check position.

After the incident, staff were sent a short email reminding them of the importance of correct tube placement.

''They almost killed my son and yet haven't changed their culture,'' Dr Wilks said. ''This is not an error made by one person. It was a group of people, which means there must be a systemic or cultural problem, and I want to make sure they can't do it again. I don't want them punished; I want them educated.''

Dr Wilks, who also has three teenagers, had bought a house in Hobart the day Francis was admitted to hospital and has been commuting twice a week to be with him. Yesterday the hospital offered to reimburse her air fares and promised a new policy would be in place by the end of the month.

But she is adamant the offers were made only because she contacted the NSW Health Minister, Carmel Tebbutt, last week.

''It's been an unconscionable length of time. An apology now is worse than no apology at all. There is nothing I can do to reverse the damage done to Francis but, at the very least, the hospital needs to ensure this doesn't happen to other children.''

A spokeswoman for the hospital yesterday said staff had verbally apologised to Francis's family. She said a statewide safety notice had been issued in February and a compulsory education program was being developed for all staff inserting feeding tubes, but it was not known when it would begin.

''The hospital sincerely regrets this incident and how it has affected Francis and his family. We are not denying we made a mistake, and we are sorry about it.''


Cazzie!!! said...

That is so bloody frightening and un believable..and they would dare call themselves professionals? HUH!
We do not EVER use a NGT without it first being X Rayed and CLEARED by a Doctor for safe use..for feeding and/or medication use. Years go, yes, we used to use the litmus paper method to test if the NGT was in the right spot or not.
I still, to this day, listen with my stethescope to make sure I hear air is going into the right spot..and I also do use the litmus paper test once a shift.
Those NG tubes can moke sometimes and well, as can be seen here... if it s not in the correct position you will cause so many waful complications.... including infective pneumonia secondary to food and/or medicines going directly into the lungs.
Therese, it is just unbelievable in this day and age..we have so much knowledge on what not to do...and great training to know what to do... and most nurses have "nursing intervention" so someone ought to have pulled up someone at that work know... grr!

Mom said...

Very scary! As a nurse I know bad stuff can happen, but this is inexcusable and should never have happened, and having happened should have been detected much earlier. Just Awful

Random Thinker said...

I want to say unbelievable but that wouldn't be true. Unfortunately it happens often enough to be believable. Too bad the hospital is so busy worrying about their liability they can't take the steps necessary to prevent it from happening again.

Middle Child said...

Cazzie I contacted this little boy's mother and she was interested in how you do the insertion so I sent what you wrote (minus I.D.) to her. Thank you very much.

Mom - and so a little boy already disabled now has even more problems to deal with and the powers that eb don't give a fig -

Random Thinker - they will never change - we have to make them change and the time is coming if I can help it.

Sara said...

Good god. That's all.