A nonradiologist physician's interpretation of an after-hours x-ray of a U.K. man undergoing cardiac arrest may have led to the incorrect placement of a feeding tube that contributed to his death, according to a published report.
According to testimony heard at a local inquest, Howard William Crabtree was taken to Royal Blackburn Hospital in September 2017 after experiencing cardiac arrest and was placed on life support after suffering a significant brain injury, according to an article in The Citizen. Over the next three weeks at the hospital, he developed pneumonia, which may have occurred due to incorrect placement of a ventilator.
Doctors decided to place a feeding tube in Crabtree and use x-ray to determine its positioning. X-rays at the hospital are usually performed between 8 a.m. and 4 p.m. so they can be interpreted by a radiologist, but due to delays the x-ray was not acquired until after 8 p.m.
A nonradiologist physician incorrectly interpreted the x-ray, and the feeding tube was placed in Crabtree's left lung rather than his stomach. Crabtree died the next day, according to the article.
The hospital has made changes to its protocol to ensure that all x-rays -- even those acquired after hours -- are interpreted by a radiologist, the story stated.
