25 January 2013 A PATIENT choked to death after a nurse missed a “nil by mouth” sign above his bed, an inquest heard.
The nurse who gave Norman Betchley, 81, a tablet and a glass of water ran from the ward crying: “I’ve killed him.”
Even though he was seriously ill, the coroner decided the tablet probably caused his death.
Mr Betchley was at Colchester General Hospital, Essex, when agency nurse Kirsten May gave him the heart drug furosemide with a glass of water.
He started choking, coughing and vomiting when he tried to take the tablet.
Nurses used suction equipment to clear Mr Betchley’s airways but he died soon after.
Coroner Tina Harrington told the inquest Mr Betchley suffered from asbestosis and his overall physical condition was sufficient to cause death at any point.
However, it was likely administering the medication would have caused his death.
She said: "He immediately began to cough and choke, which caused obstruction to his airways, which I find on balance precipitated Mr Betchley’s death.”
Miss Harrington said she was satisfied Colchester Hospital University NHS Foundation Trust, which runs the hospital, had made strides since Mr Betchley's death and she did not make any recommendations.
The nurse ran from the ward crying: “I’ve killed him.”
She claimed not to have been told during the morning handover that Mr Betchley was “nil by mouth - a medical instruction for patients who may not take any substances orally.
Mr Betchley, of South Green Road, Fingringhoe, died on April 9, 2009 having been admitted to Birch ward on February 10, 2009 suffering with breathing difficulties.
Two post-mortem examinations found Mr Betchley's cause of death to be lung disease due to exposure to asbestos.
Det Chief Supt Liam Osborne investigated Mr Betchley’s death and found nine members of staff, including Ms May, had been briefed properly.
He decided neither Nurse May nor Colchester General Hospital had a criminal case to answer.
A spokesman for Colchester Hospital University NHS Foundation Trust extended its condolences and sympathy to Mr Bletchley’s family and friends.
He said: “We fully accept we failed in our duty of care to him and apologise unreservedly.
“The nurse involved in this case, who was not our employee, had not followed Nursing and Midwifery Council or our own guidance relating to the administration of medicines and was suspended immediately.
“We immediately notified the authorities and a matron met Mr Betchley’s son and daughter on the day of his death to tell them about the investigation the trust was about to start.
“She met them again to share the outcome of the investigation and resulting action plan which contained eight recommendations. They were all implemented.”
Senior staff told the hearing of the measures taken to minimise the risk of a repeat, including an improved handover between shifts and more conspicuous nil by mouth signs.
 
THE son of a man who died after being given a tablet in hospital in error says he hopes the hospital has learnt from its mistakes.
Stuart Betchley’s dad Norman Betchley choked when an agency nurse gave him a tablet despite a “nil by mouth” sign set on his bed.
Even though he was seriously ill the coroner decided the tablet probably caused his death.
Stuart, of South Green Road, Fingringhoe, said: “This whole thing should not have to happen to anyone.
"Two reports into dad's death said the tablet contributed to his death and we heard how the nurse herself screamed when she realised what she had done
“It was an unfortunate mistake and I do not blame anyone in particular, but the system is lacking.”
“If you go to hospital and there is no clear diagnosis, as was the case with my dad, you are just passed from pillar to post.
"I hope the hospital has taken this seriously and implements all the changes it has stated.”
Mr Betchley had been admitted to Birch ward at Colchester General Hospital after suffering from breathing difficulties and died two months later on April 9, 2009.
The former guillotine operator was due to be assessed for the Liverpool Care Pathway, which dictates patients should not be resuscitated, on the day he died.
Stuart was also critical of the inquest system.
It has taken nearly four years for the inquest, which determined how Mr Betchley died and did not attribute blame, to be concluded.
He said: “I would like to think someone would not have to wait four years for this as we have, and for what?
"No one will argue my dad was not in good health but I know he would not have died that particular day if this had not happened.
“It seems we will never get a straight answer.”