Nil by mouth patient ‘choked on sausage & mash’

A HEALTH board has been fined £40,000 for causing the death of a nil by mouth patient after a student nurse gave him sausages and mash for lunch.

Raigmore Hospital in Inverness. The 51-year-old choked to death on his meal. Picture: PA

James South from Aviemore was being fed via a tube through his nose and had a sign above his bed in the Highlands’ biggest hospital with the words “nil by mouth” written in red pen.

But an auxiliary nurse helped him fill out his lunch menu and a student nurse handed him his soup, sausages and ice cream in Ward 11 of Raigmore Hospital in Inverness in February 2014.

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Fifteen minutes later, the 51-year-old was dead, having choked to death on his meal.

His 82-year-old mother, Sandra South, from Grantown on Spey, was in court to hear the circumstances leading up to the death of her son.

She said: “The fine is fair. It is not the money, but the principle which concerned me. James had been doing so well.

“But the human element came into it. I do not bear any grudges and want to say that the care he received in intensive care was wonderful. However I wouldn’t like to comment on what I think about ward 11.”

Ward 11 is the respiratory unit of Raigmore and measures were in place to ensure each patient’s dietary requirements were met and communicated to staff at safety briefings and shift 

Mr South was admitted on 27 December, 2013 suffering from a variety of health conditions including pneumonia. But three days later, he suffered respiratory failure and was transferred to intensive care and put on a ventilator. On 1 January, the decision was taken to feed him through a nasal tube and when his condition improved, he was again transferred to Ward 11 because “swallowing was not felt to be safe”, fiscal depute Geoffrey Mayne told the court.

He added that a student nurse was on her first day on the ward and a staff nurse, who was aware of Mr South’s limitation, was assigned to oversee her.

“However the staff nurse became severely unwell and another staff nurse was assigned. An auxiliary, who had attended the handover, but was unaware that Mr South was nil by mouth, then began collecting menu cards.

“She asked him what he wanted and she completed the card for him. A consultant visited Mr South and asked how staff could make him more comfortable to which he replied that he wanted to eat.

“The consultant explained that he was unable to eat due to swallowing problems.”

However later that day, the meal was delivered to Mr South by the student nurse.

“Fifteen minutes later, during the routine post meal check, Mr South was found to be unresponsive. Mashed potato was noticed on the side of his face and inside his oxygen mask.”

NHS Highland admitted a breach of health and safety.

Their counsel, Peter Gray QC said: “This was an isolated failure at operational level. The failing relates to one ward in one hospital on one day.”