Andrew Kenyon: family of Preston man want lessons to be learned after inquest reveals hospital error

Preston Coroner's Court heard on Thursday that 47-year-old Andrew, from Tanterton, Preston, died several days after he pulled a feeding tube out and it was reinserted.

He suffered a perforation to his abdomen, and died five days later from sepsis.

Although the inquest did not apportion blame, individual errors in Andrew's care were highlighted, and his family – who brought his ashes to the hearing – say they want lesson learned so that nobody else has to go through the same ordeal and his death is not in vain.

What’s the background to Andrew Kenyon’s death?

Andrew, a caretaker, suffered a cardiac arrest in 2018 after taking illicit drugs. As part of this, he suffered a hypoxic brain injury, which meant he had severe physical and cognitive disabilities and required round-the-clock, one-to-one care.

He became a resident at Moor Park House Care Home in Preston and because of his inability to swallow, needed all his nutrition delivering through a peg tube through the wall of his abdomen.

Lindsey Bowser, manager of the home, said that Andrew “exhibited challenging behaviour”, “always had some frustration around his peg tube” and would “quite often go to pull the peg tube”.

In her testimony she claimed that she knew of three occasions where he had pulled it out.

What happened leading up to Andrew Kenyon's death?

At 8am on May 21, 2021, day staff at the home were made aware that Andrew had removed his peg tube about 10 minutes previously.

An experienced nurse reinserted the tube soon afterwards, but was unable to get a pH reading which helps tells medics if the tube is in the stomach properly.

Royal Preston Hospital’s nutrition team recommended moving Andrew, but still a reading couldn’t be taken.

Mrs Bowser said: “The peg was inserted as per standard procedure- to the correct centimetre as per the care plan. The nurse didn’t report any signs of resistance or blood”.

As it was not deemed safe to deliver anything down the tube, attempts were made to contact the hospital’s endoscopy unit, without success.

After several hours it was noted that Andrew started showing abnormal vital signs and an ambulance was called.

What happened to Andrew at Royal Preston Hospital?

Andrew was seen at the A&E department of the Royal Preston Hospital and administered treatment for his epilepsy and broad spectrum antibiotics intravenosly, as there was concern he could have a chest infection due to his high temperature and infection markers in his blood.

Nutrition nurse Pamela Boyes saw Andrew the day after his admission and inspected his peg tube.

She said the distance marker was 4cm - as per his care plan - and said "there was nothing to suggest the position was wrong".

However, she took a pH reading of 8, which was too high, and indicative of the tube not being in the stomach properly.

She planned an out-of-hours pegogram to determine whether the tube was in the right place, but felt this "was not urgent" as Andrew was receiving fluids and medication intravenously.

The pegogram

The pegogram was carried out on Sunday, May 23. Two X-rays were taken of Andrew's abdomen before any fluid was put down the tube, and two X-rays were taken when contrast - a liquid which shows up on X-rays - was put down it.

The report produced afterwards by consultant radiologist Ibraham Niemitatallah said the tube was within the stomach and could be used for feeding.

Royal Preston Hospital error

Dr Niemitatallah was given the four X-rays to review and was the person who determined the tube was in the right place.

But he only looked at three of the four X-rays, and failed to spot that the fourth showed the contast liquid leaking from the stomach into the abdominal cavity.

He said: "I did not anticipate there would be a fourth image, there's usually only one or two images."

He also said that of the three monitors he had, one showed patient information and two shows one X-ray image each, not the full range. He also said the on-call department was "very busy that day".

When challenged over why he hadn't seen the fourth image, he reiterated: "Once I reached the third X ray I was satisfied. Normally we get only one contrast".

Andrew's father William Bloomfield said: "I'm not happy with all of these usually's and normally's."

Dr Niemitatallah said that since Andrew's death, there have been changes to allow him to see up to four X-ray images on a single screen and he was confident that he would now see all images.

Consultant radiologist Dr Thind gave evidence saying a warning triangle now showed up if all images had not been seen and that staff had been made aware of how to check for more X-rays.

What happened next?

Believing that the tube was in the correct place, feeding through it recommenced.

However, Andrew's condition continued to decline, and by May 25, the infection markers in his blood were "extremely high".

There were was no signs of severe inflammation from his stomach, and a chest scan was arranged.

By 11pm that day Andrew's early warning score had increased to 10, his breathing rate had increased and his oxygen levels were low.

A chest X-ray revealed free air under his diaphragm which was indicative of perforation, and an urgent CT was ordered.

The CT scan carried out early on May 26 revealed the tube was not correctly positioned inside the stomach.

It also showed a lower lobe collapse, pnuemonia forming and lots of air and fluid under his diaphragm – likely from the stomach.

By 9am on May 26, Andrew’s kidney function began to deteriorate, and at 11am surgery was deemed inappropriate due to his frailty.

He died with his family by his bedside at around 10.30pm.

So did the pegogram error hasten Andrew's death?

Doctors say not, and coroner Chris Long was happy to accept that view.

Dr Sharma, a gastroenterologist at LTH said: "Even if Andrew had not had any feeding at all, it's very, very likely Andrew would have had an infection quickly."

Adding: "On the balance of probabilities, the chances of Andrew surviving a significant perforation would still have been very slim in my view."

When asked by the coroner if treatment differences had the pegogram been viewed properly would have prolonged Andrew's life, Dr Sharma said: "Probably not".

This was due to the fact he was already receiving the main treatment of stong antibiotics and still demonstrated as sharp rise in infection.

What caused the perforation?

Dr Sharma said it was likely that the perforation occurred before Andrew arrived at hospital, but was unable to say how it had happened.

He said: "It is difficult to know exactly what happened. If a peg with a balloon is pulled out, it can damage the tract. If another tube is inserted, it might not go in far enough and could damage the tract."

The conclusion

Mr Long gave a narrative conclusion, detailing the events leading up to Andrew's death.

He said the medical cause of death was sepsis caused by perforation of the abdominal viscous and dislodgement of the peg feeding tube.

He said: "I haven't found in anyway care should have been received differently" and "on the face of the evidence, all steps had been taken to put the tube in the right place."

He added: "There is nothing suggestive of culpable human failure in relation to the placement of the tube", and was satisfied that although there was a delay in Andrew's care due to the pegogram error, "any other treatment from the 23rds (May, 2021), wouldn't have made any difference."

Speaking to the family, Mr Long said: "I hope very much that brings some sense of peace"."

What do the family think?

Andrew's mum Alison Broomfield said the inquest had brought a sense of closure, but that there were "still a lot of unanswered questions".

She said: "I can't understand how he could be pulling his peg out when he was getting one-to-one care."

She said: "We're never going to bring Andrew back, but I want to try and make sure that we're speaking for those who can't speak for themselves and we stop it happening again.

"I don't want his death to be in vain."

Moor Park House Care Home has been contacted for comment.