A pensioner died after a nasal feeding tube was inserted into his lung at St Helier Hospital, causing "catastrophic" medical complications, a coroner has ruled.

Medical neglect contributed to the death of David Charles Morey, 87, of Burleigh Road, Sutton, who died three days after a nurse failed to follow hospital policy by fitting the tube before day staff arrived on the ward.

Last year: Hospital patient's feeding tube inserted into respiratory tract in 'never event'

Nurse Jacqueline Nyame’s mistake was only noticed when approximately 100ml of fluid had already been funnelled into Mr Morey’s respiratory system, causing him to become distressed.

Assistant coroner Adela Williams ruled, despite Mr Morey’s advanced age, he would not have died if the complications were avoided on May 3 last year.

The misplacement of the nasal tube caused “catastrophic deterioration of his condition,”  she told Croydon Coroners’ Court today at the conclusion of a two-day inquest today.

Neglect was also a contributing factor, the coroner ruled, after hearing paperwork that should have noted other occasions the 87-year-old’s nasal feeding tube was wrongly fitted was not kept up to date.

She said: “My conclusion is going to be that he died of complications of nutritional support to him, for which neglect contributed.

“There is the irresistible conclusion that he would not have died if it was not for this."

But Ms Williams said she was satisfied Epsom and St Helier Hospital Trust have since put plans in place to avoid similar complications.

Speaking after the coroner returned her findings, Mr Morey's daughter, Michelle Posmentier, said her dad had suffered "such a horrible way to die”.

She said: “He had so many years ahead of him... It wasn’t over for him. Just before the stroke he was asking his home-helper for more activities to do. He was outgoing, creative and always active. Always smiling, he was.”

“It’s good that now there are plans in place for preventing this from happening in future, so that hopefully this will never happen again to another family. It is such a horrible way to die.

But she added: “I know that he would be pleased that his voice has been hear, in a way, and that changes have been made.”

Mr Morey was first admitted to St George's Hospital on April 26 last year after he suffered a stroke following a fall at his home.

He was transferred to St Helier hospital on April 29 after doctors deemed his condition stable.

Overnight on May 2, a night nurse noticed the pensioner’s feeding tube had been dislodged and was pouring over his chest.

She fitted a new tube, around 7am on May 3, and began his feed - not realising the tube was fed into Mr Morey’s right lung rather than his stomach until she noticed he was distressed 20 minutes later.

Ms Nyame tested the PH level of the fluid in the tube, which she said was recorded as 3 – an acidic PH level that would suggest the tube was correctly placed in the stomach – before she commenced Mr Morey’s feed.

The complications that led to Mr Morey’s death three days later, on May 6, were classed as a ‘never event’ - an error so serious it should never happen.

Laila Mazin, who was on call at St Helier at the time, said: “I was aware that a tube should not be replaced overnight because of the potential risk of complications.

“For emergency medication, I think, it would have been slightly different.

“It is a ‘never event’, and there should be safeguards in place to ensure that even if it is in the lung, that nothing is administered there.”

The trust’s policy at time set out that no feeding tube should be replaced unless between the hours of 8am to 4pm - when daytime staff are on the ward.

Ms Nyame admitted she should have challenged her manager’s decision to recommence feeding and to re-insert the feeding tube.

Other factors deemed a cause for concern by the coroner included Mr Morey’s nasal tubes becoming dislodged a number of times prior to the incident. They were also not always the same length, the largest margin being an 11cm differential.

Ms Kahn, representing the trust, said: “The cause [of death] is not particularly clear. There are gaps in the evidence to show that the actions of the nurse were causative of Mr Morey’s death.”

She added that the trust “really wants to learn” from the incident.

But Mr Johnathan Bertram, representing the family, said: “All of these factors, in my submission [can be] described as gross failures.

“David’s life many have been prolonged, or he would have survived.”