A elderly woman died from a combination of natural disease, stroke and the "misplacement" of a feeding tube into her lung due a hospital blunder, a coroner has said.
Andriana Georgiou, an 84-year-old grandmother, contracted pneumonia and died 11 days after the error in December 2012 at the Homerton University Hospital in east London where she was being treated for a stroke.
Finnish trained consultant Dr Kari Saastamoinen made an "error" in using the "whoosh" test to verify wrongly that the tube was correctly inserted, Mary Hassell, senior coroner for inner London north told Poplar Coroner's Court.
This was in spite of the test - where air flow is listened to in the tube to check whether it is in the right place - being the subject of three patient safety alerts since 2005, she said.
"The senior nurse asked the doctor for a check X ray but he opted instead to perform a whoosh test and he was then satisfied that the tube was in the right place - and feeding began," Ms Hassell said, returning a narrative conclusion.
"It was not - a patient safety alert on February 21 2005 and two subsequent alerts directed that the practice of using a whoosh test to check the position of a naso-gastric tube must cease immediately."
The inquest also heard that the Homerton Hospital had drawn up policy ruling out the use of whoosh test after the first patient alert was issued in 2005.
The error was made on the morning of December 4 that year but was not discovered until that evening, the inquest heard.
Nearly two litres of fluid had to be drained from her pleural cavity as a result, the inquest heard. The error occurred in spite of there being "good" systems in place at the Homerton Hospital, Ms Hassell said.
Dr John Coakley, the hospital's medical director, earlier apologised to Mrs Georgiou's family for the incident.
"I extend my condolences to Mrs Georgiou's family - I met many of her family on the intensive care unit and apologised for this incident," he said.
"It happened on a ward in my hospital on my watch and I am very, very sorry that has happened to you."
He said incidents of wrongly inserted tubes being used to administer food or drugs were "very, very rare" in the UK. Figures from 2009 showed around 20 cases in the entire UK, and where this had occurred around five patients had died.
Ms Hassell told the inquest that the misplaced tube had caused Mrs Georgiou, a retired machine operative from Tottenham, north London, "great distress".
Dr Saastamoinen told the inquest he had learned the "whoosh test" at medical school in Finland and had used it on several occasions in that country without problems. He had not been aware at the time that it was trust policy for a patient to go for a chest X ray where a litmus test indicated that there could be a problem, he said.
The inquest was told Mrs Georgiou, had also suffered from a range of conditions including dementia.