A 71-year-old retired farmer, who had beaten the odds by surviving major surgery, unexpectedly died from asphyxiation when a tracheostomy tube, which had been inserted in his throat to help him breathe, became dislodged after nurses at NUIG turned him on his side for a wash, an inquest in to his death heard last Thursday.
The Coroner’s Court heard how Frank Grenham of Falty, Oldtown, Athlone, had initially been admitted to Portiuncula Hospital in Ballinasloe but was immediately transferred to NUIG suffering from a ruptured aortic aneurism on June 28, 2007. However, following successful surgery, Mr Grenham had unexpectedly died on July 6, when medics “were washing his back”, his son Enda told the court.
A staff nurse gave evidence that before midnight on June 5 she had queried a “leaking” sound coming from the patient. However, after consultations with a senior nurse and a doctor everything was found to be normal. She said that due to a request from the patient she began to wash him at 5.15am on July 6 with the assistance of a senior nurse and a care assistant. However, when Mr Grenham was turned on his side an alarm sounded on the ventilator. He was immediately put on his back and attempts to ventilate or “bag” him manually failed.
Dr Donal Courtney then gave evidence that Mr Grenham that the operation to repair the ruptured aneurism had been “stormy”. However when he was moved to the intensive care unit Dr Courtney said that his “condition slowly improved”. He added that his recovery had been impressive as eighty per cent of patients with a ruptured main vessel never even made it to hospital and out of the 20 per cent who did half of them did not survive.
Consultant anaesthetist, Dr Brian Harte, said that the tube had been held in position by tape and velcro ties. He said that the loss of ventilation and the “bagging” caused the surgical emphysema and a major problem with the false passage occurred when the tube “didn’t come out all the way”. Regarding the “leaking sound” Dr Harte said that if all “ventilator parameters are normal, and patient is sitting up and responding” then this would be “tolerated”. Dr Harte said that the tie used to secure the tube is standard practise in all hospitals however following this incident the hospital have been discussing the possibility of reviewing the process.
Consultant pathologist, Dr Teresa McHale said that Mr Grenham had had a previous heart attack, suffered from a rapid irregular heart beat and had two stents inserted into coronary arteries. She that the tracheostomy tube had become displaced and had entered a “false passage” (when the tube travels in to the soft tissue and instead of air getting into the trachea (windpipe ) it goes in to the tissue causing surgical emphysema ).
After hearing the evidence presented, West Galway Coroner, Dr Ciaran McLoughlin, said that he would describe the incident as an “accident not misadventure as no one could have anticipated it”. Dr McLoughlin then recorded the verdict that Frank Grenham had died from asphyxia due to the interruption of the ventilation as a result of the tracheostomy tube re-siting in a false passage anterior to the trachea. To Mr Grenham’s family Dr McLoughlin offered his deepest sympathies for the untimely death.
