A HOSPITAL has reviewed its procedures after an incorrectly inserted tube contributed to the death of an alcoholic with chronic liver disease.

Teesside Coroner's Court was told that junior doctors and staff at the University Hospital of North Tees were given refresher courses. The patient contracted pneumonia after a nasal gastric tube was inserted into his left lung.

Dr Jane Metcalf, consultant gastroenterologist, apologised to the family of Jeffrey Smith after the mistake contributed to his death.

"This was an error - there is no getting away from it," she said.

Mr Smith, of Kirkdale Close, Stockton, was in the hospital receiving treatment for liver problems in August last year when he ripped out the first tube that had been correctly inserted. When it was replaced, it was not located properly and this led to Mr Smith's chest infection, the court heard.

Pathologist Jan Lowe said: "Chest infections and pneumonia are common conditions and the affects can be associated with liver failure. When that is the case, both lungs would show similar changes.

"In the case of Mr Smith, it was only his left lung that showed marked signs of inflammation, while his right lung showed only minor changes.

"The fact was that one lung, which was the one with the nasal gastric tubing inserted, showed more significant signs of infection.

"This suggests to me it was the misplacement of the tubing that precipitated the pneumonia."

Teesside Coroner Michael Sheffield recorded a verdict of misadventure.

He said Mr Smith, 39, died from liver failure and this was the result of alcoholic liver disease, with pneumonia from the misplaced nasal gastric tube contributing to the death.

Speaking after the hearing, Dr Metcalf said: "This is clearly a tragic case, and our sympathies go to Mr Smith's family at this very difficult time.

"Many lessons have been learned. All staff have been reminded about nasal gastric tube insertion. Confirmation that the location of the tube has been checked is now recorded in the patient's notes.

"The measures we have now introduced provide checks and balances which, as far as humanly possible, will ensure this never happens again."