Coroner's Finding: Fenton, Timothy John

57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia

Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was dislodged on 29 August and not reinserted during the morning ward round despite clinical stability. Later that day, when the tube was reinserted and a chest x-ray confirmed correct gastric placement showing gaseous distension, the tube was not aspirated to decompress the stomach. Within one hour, Mr Fenton aspirated gastric contents, developing aspiration pneumonia, acute respiratory distress syndrome, and ultimately sepsis with multiple organ failure leading to death on 1 October 2017. The coroner found the failure to aspirate the nasogastric tube after confirming correct placement was a departure from reasonable medical care that directly contributed to death.