Brockel, Ronald James

64y · Male·aspiration pneumonia following insertion of a jejunostomy tube

Ronald Brockel, a 64-year-old with cerebral palsy, oropharyngeal dysphagia, and recurrent aspiration pneumonia, underwent insertion of a feeding jejunostomy tube (FJT) on 23 December 2004 to bypass his stomach and improve nutrition. The tube was misplaced in the terminal ileum rather than the jejunum. This positioning error, undetected until late April 2005, compromised nutrient absorption (primarily occurring in the jejunum) and likely contributed to his severe malnutrition and weight loss over six months. Though confirmation bias led clinicians to accept the surgeon's assurance of correct placement, a CT scan should have been ordered by late March/early April when the patient failed to thrive despite increased feeding. Dr O'Rourke's technique was standard; the error resulted from Mr Brockel's anatomical complexity, not negligence. Following replacement of the tube on 8 June 2005, he aspirated and died of aspiration pneumonia on 10 June 2005. The hospital's failure to acknowledge the error for over three years was problematic. No disciplinary action was warranted, but the case illustrates the importance of considering tube misplacement in patients failing to thrive post-operatively and the cognitive bias risks in surgical cases.