A coroner has found that the death of a 68-year-old woman following surgery for a bowel obstruction was preventable. Janet Layland died on 1 August 2020 at the Ulster Hospital in Dundonald, one day after undergoing a laparotomy. Coroner Maria Dougan ruled that missed opportunities to identify and replace a blocked nasogastric (NG) tube before the operation led to pulmonary aspiration during anaesthesia and a catastrophic cascade of organ failure.

Mrs Layland, from Portavogie, Newtownards, was admitted to the Ulster Hospital on 28 July 2020 with a two-week history of vomiting and abdominal pain. She was diagnosed with a small bowel obstruction caused by adhesions from previous surgery. Initially managed conservatively with intravenous fluids and an NG tube to decompress her stomach, her condition failed to improve, and surgery was scheduled for 31 July 2020.

The inquest heard that the NG tube had drained approximately 1.5 litres of fluid on 29 July 2020, but output ceased thereafter. Records showed repeated nil aspirates over the following 24 hours, yet no concern was raised. On the morning of surgery, the tube was aspirated again with no result. Consultant surgeon Robert Kennedy noted '0ml up NG tube' in his ward round entry but did not communicate his suspicion that the tube might be blocked to the anaesthetic team. Consultant anaesthetist Terence Boyd, who performed the pre-operative assessment, did not review the fluid balance chart from the previous day and was unaware of the prolonged absence of drainage.

At induction of anaesthesia, faeculent fluid was observed in Mrs Layland's oropharynx. Rapid sequence induction was performed and the airway secured, but she immediately developed severe oxygenation difficulties. The anaesthetic team removed the original NG tube and replaced it, finding it physically blocked. Approximately 2.5 litres of gastric contents were then aspirated. The coroner accepted expert evidence that Mrs Layland had suffered a significant pulmonary aspiration at induction, which triggered a profound systemic inflammatory response leading to refractory multi-organ failure. She died in intensive care at 05:20 on 1 August 2020.

The coroner found a series of failures in monitoring, documentation, communication and escalation. Nursing records did not demonstrate consistent four-hourly aspiration as ordered, and the fluid balance chart failed to distinguish between aspirated volumes and free drainage. Staff Nurse Aleyamma Binny, who cared for Mrs Layland on the day of surgery, believed the absence of aspirate was due to the stomach being empty because the patient was nil by mouth. She did not consider tube blockage. Deputy Sister Michelle Kerr accepted that she did not document the rationale for not escalating concerns over missing NG output.

Medical staff also missed opportunities. Mr Kennedy acknowledged that had he recognised the significance of the absent drainage on 30 July, he would have instructed the tube to be changed that evening. Dr Boyd described his failure to review the relevant fluid balance chart as a 'missed opportunity'. The coroner found that communication between nursing and medical teams was inadequate, with relevant information known to members of both teams but not brought together or acted upon.

Expert evidence from Dr Paul Glover, a consultant in critical care and anaesthesia, concluded that a patent NG tube would have significantly reduced the risk of pulmonary aspiration. He stated that the abrupt change from significant drainage to no output should have prompted reassessment. Expert nursing evidence from Maggie Gairdner highlighted the absence of a nursing care plan for NG tube management and criticized the quality of documentation. She noted that the first nil aspirate should have triggered escalation.

The coroner ruled that the death was due to multi-organ failure caused by pulmonary aspiration associated with a blocked NG tube, in the setting of small bowel obstruction requiring laparotomy. She acknowledged that the severity of the inflammatory response was unusual and could not have been foreseen, but she was satisfied that the aspiration was the precipitating event. She also noted that the intensive care treatment provided was appropriate, but by then the damage was irreversible.

In response to the death, the South Eastern Health and Social Care Trust revised its NG tube policy, which now includes specific guidance for drainage tubes and a decision pathway when aspirate cannot be obtained. It also developed training for nursing staff. However, the coroner said the revised policy does not expressly identify a prolonged absence of drainage in the context of ongoing bowel obstruction as a trigger for escalation and tube replacement. She recommended further clarification to prevent similar deaths.