Recurring concern

Unreliable tracheostomy tube management and safety controls

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First reported 5 Jun 2014•Latest report 8 Jan 2024

Definition

What this concern includes

Includes failures in dedicated tracheostomy-tube management controls, including tube selection and suitability, attachment and securing, tube changes, emergency replacement capability, clinical presence or supervision, staff competence, and guidance for anaesthetic, intensive-care, community or home management.

Not included

  • Excludes mini-tracheostomy procedures, endotracheal tubes, nasogastric tubes and other non-tracheostomy airway or feeding-tube processes.
  • Excludes generic staffing, training or communication deficiencies unless they directly impair a tracheostomy-tube management control.
  • Excludes failures in treating complications after the tracheostomy-tube management process has operated reliably.
  • Excludes unrelated product, clinical-care or emergency-response failures where tracheostomy-tube management is not the deficient process.
Reports
4

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Association Of Anaesthetists (Great Britain & Ireland)1
Care Quality Commission1
Department of Health and Social Care1
Epsom and St Helier University Hospitals NHS Trust1
NHS England1
Queen Mary's Hospital for Children1
Royal College of Anaesthetists1
Surrey Community Health1
The Intensive Care Society1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Sussex, Brighton and Hove

    AI-generated summary

    David Bryan Moore · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of guidelines for anaesthetic and/or Intensive Care management of a flanged tracheostomy tube

    Wider context from the report

    “1. Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube ”

    Source location

    David Bryan Moore · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop, publish and disseminate tracheostomy-care guidance, including guidance for adjustable flanged tubes.

    Verbatim wording from the response

    “Your prevention of future deaths report highlighted your concern regarding the “Guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.” The College, FICM and ICS have worked with the NTSP to develop, publish and disseminate guidelines for tracheostomy care since 2012. This was in response to critical incident analysis research that identified recurrent themes in the management of tracheostomies in anaesthesia, critical care and hospital wards that led to patient harm. We have summarised key references below, and summarise key points from these existing documents below, with respect to general tracheostomy care and in the specific case of adjustable flanged tracheostomy tubes.”

    Source location

    Response from Response from RCOA
    Page 1 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Participate as stakeholders in reviewing and revising tracheostomy emergency-management guidelines.

    Verbatim wording from the response

    “The NTSP had agreed with the Difficult Airway Society in 2023 to review and revise the current guidelines for tracheostomy emergency management. The Royal College of Anaesthetists, Association of Anaesthetists, Faculty of Intensive Care Medicine and the Intensive Care Society will be stakeholders in this update, which will ensure that updated guidance will be appropriately disseminated. Other stakeholders representing the multidisciplinary team involved in tracheostomy care will also be involved, including head and neck surgery, nursing, physiotherapy, and speech and language therapy. We anticipate publication of updated guidelines in 2025. Index cases such as the case of Mr Moore help to inform updates to such guidance where necessary and we thank you for bringing this case to our attention.”

    Source location

    Response from Response from RCOA
    Page 2 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use safety publications to share learning from Mr Moore’s death and re-promote tracheostomy guidance to members.

    Verbatim wording from the response

    “SALG publishes regular Patient Safety Updates, which are distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. FICM publishes regular Safety”

    Source location

    Response from Response from RCOA
    Page 2 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Writing national guidance on adjustable flanged tracheostomy care falls outside the regulator’s remit.

    Verbatim wording from the response

    “We have given careful consideration to the concerns raised and have come to the conclusion the concerns identified, namely; ‘that there is a lack of guidance for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube’ regretfully sits outside of CQC remit.”

    Source location

    Response from CQC
    Page 1 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specific guidance may be written by the Association of Anaesthetists, Royal College of Anaesthetists, or Health Education England.

    Verbatim wording from the response

    “Other bodies who may be able to assist with the writing of specific guidance could include the Association of Anaesthetists Great Britain and Ireland, the Royal College of Anaesthetists or Health Education, England, all of whom I note have been included in your report.”

    Source location

    Response from CQC
    Page 2 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    National resources and guidance already address the management and safety of flanged tracheostomy tubes.

    Verbatim wording from the response

    “The National Tracheostomy Safety Project (NTSP) exists to provide a wide range of resources, materials and e-learning to support healthcare professionals with responsibility for providing care for patients with tracheostomies, for both general and emergency care. The website includes guidance on the different types and features of tracheostomy tubes, including flange tubes (NTSP Manual 2013 (tracheostomy.org.uk)), red flags for tracheostomy emergencies, which includes displacement, as well as day-to-day management and checks.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Association of Anaesthetists and Royal College of Anaesthetists are better placed to respond on national guidance for flanged tracheostomy tubes.

    Verbatim wording from the response

    “NHS England notes that you have also addressed your concerns to the Association of Anaesthetists Great Britain and Ireland and the Royal College of Anaesthetists. These organisations are better placed to respond to your concerns over national guidance for flanged tracheostomy tubes.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 11 January 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commissioners and providers are responsible for developing and implementing local policies and guidance within their context.

    Verbatim wording from the response

    “Commissioners and providers have a responsibility to ensure local policies and guidance are appropriately developed and implemented within their local context and regarding national guidance/guidelines. NHS England has engaged with Queen Victoria Hospital NHS Foundation Trust on the concerns from your Report and understand that a new local protocol they have developed has also been shared with the coroner.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 11 January 2024

    Open published response

  2. Inner South London

    AI-generated summary

    Christ Morrison · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christ Morrison was born at 24 weeks gestation in 2005 and developed chronic lung disease requiring a tracheostomy. On 10 September 2014, the tracheostomy tube was removed and could not be replaced; despite resuscitation and transfer to a specialist centre, he died on 17 October 2014. The principal concerns were the training required for staff changing children's tracheostomy tubes at home, the absence of medical presence, and the lack of provision for an emergency tracheostomy when replacement failed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure staff are skilled and equipped to perform an emergency tracheostomy after failed tube replacement

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”

    Source location

    Christ Morrison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity about necessary training levels for staff changing children's tracheostomy tubes at home

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”

    Source location

    Christ Morrison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide medical presence during children's tracheostomy tube changes at home

    Wider context from the report

    “It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence. It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case. Whilst processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to A&E rather than emergency tracheostomy and does not require a medical presence. ”

    Source location

    Christ Morrison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide mandatory annual paediatric life-support training, completed competencies, and yearly simulated tracheostomy training updates for community staff.

    Verbatim wording from the response

    “The level of training for staff carrying out or assisting a parent with routine tube changes would be as above for the parents/carers with the addition of:”

    Source location

    2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
    Page 3 · response
    Published 2 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the paediatric tracheostomy policy to provide clearer signposting to the NTSP emergency management algorithm and require Emergency Department review after life-threatening events.

    Verbatim wording from the response

    “However, as a result of the inquest and the Report, the Trust has reviewed its procedures within the policy and has strengthened this section which now signposts staff further to follow the NTSP (2014) algorithm for Emergency Paediatric Tracheotomy Management (copy enclosed). This is now clearer in the body of the policy.⁴”

    Source location

    2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
    Page 5 · response
    Published 2 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require two competent carers for planned paediatric tracheostomy tube changes, with two community nurses attending when families request community support.

    Verbatim wording from the response

    “For all planned tube changes there must now be two competent carers present.”

    Source location

    2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
    Page 3 · response
    Published 2 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Nurses cannot be trained to perform emergency tracheostomies because the procedure is high-risk and outside registered children’s nurses’ competence.

    Verbatim wording from the response

    “Emergency tracheostomy, even performed by two competent, skilled, specialist surgeons, in ideal operating theatre facilities with all the relevant lighting, instruments and anaesthetic support is a high-risk, invasive procedure with an associated mortality, 2-3 times higher in children than adults. (Alladi A, Rao S, et al 2004).”

    Source location

    2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
    Page 4 · response
    Published 2 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Medical presence at home for routine tracheostomy changes is not practicable because medical teams cannot reliably provide home visits.

    Verbatim wording from the response

    “Families are also offered the opportunity to have routine tube changes carried out in the clinical setting / hospital where medical staff are available. This option is sometimes a mandatory arrangement in the event of a child with known difficulty or high risk of complications at tube changes. With regard to medical presence at home, this is not practical due to the availability of the medical team to carry out home visits and also that carers must feel confident in performing emergency tube changes at home / school when there are no professional available.”

    Source location

    2016-0084-Response-by-Epsom-and-St-Helier-NHS-Trust
    Page 3 · response
    Published 2 March 2016

    Open published response

  3. Cardiff and the Vale of Glamorgan

    AI-generated summary

    Dilys Jenkins · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dilys Jenkins, who had undergone cardiac surgery and subsequently required a tracheostomy, died after the tracheostomy became dislodged, leading to respiratory and cardiac arrest. The Coroner was concerned that the tube’s length may have contributed to the dislodgement and that tracheostomy design and sizing had not kept pace with increasing population size.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of tracheostomy tube lengths to match increasing patient size

    Wider context from the report

    “Both ████████ and ████████ were of the view that the tracheostomy manufacturers had not kept pace with the developments in the population towards larger size. The tracheostomy was a size 8 Portex tracheostomy tube which I heard had a length of 75.9 mm ████████ gave evidence that nowadays this length can be inappropriate and that a length of 85.9 mm may be more desirable. They both referred to learned papers which enclose with this Regulation 28 Notice. I have had regard to Chapter 15 in particular of the paper “Major complications of airway management in the UK” (March 2011) and to the article in Anaesthesia 2008, 63, pages 302 – 306 “An investigation into the length of standard tracheostomy tubes in critical care patients”. This recommendation that the length of the tube be increased by 1 cm and the tube redesign to an angle of 110 – 120 degrees to allow optimal tracheal placement. I concluded that the tube will not lie comfortably if its stoma or intra-tracheal length is too short or too long. While the cause of the dislodgment in the case of Dilys Jenkins is unknown the Coroner is concerned that incorrect length may have been a factor. The Coroner is concerned that the tracheostomy industry should be encouraged to change the length of the tracheostomy tube to match the increasing size of the population, and believes the Intensive Care Society is in the best position to influence industry in this regard. ”

    Source location

    Dilys Jenkins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Archie Hames · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Three-year-old Archie Hames, who had CHARGE syndrome and relied on a tracheostomy, was found unresponsive at home on 15 January 2012 after the tracheostomy tube had become displaced. He was resuscitated and taken to hospital, but died of cerebral hypoxia on 19 January 2012; testing indicated that the attaching Velcro strap had worn the tube’s silicone eyelet, contributing to detachment and airway obstruction.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure the integrity of tracheostomy tube attachments when using Velcro straps

    Wider context from the report

    “• Independent expert testing of the tracheostomy tube (model AMFNF-49) manufactured by Arcadia Medical and its attaching Velcro strap (model Trachi-Hold mini, TR ACC) manufactured by Kapitex Healthcare, confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of Archie’s tube • The further implications of such continued use • The implications of using Velcro strap attachments with other like tracheostomy tubes. I would ask that you consider give further consideration to the appropriateness of using Velcro strap attachments with tracheostomy tubes. ”

    Source location

    Archie Hames · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Initiate discussions with partner agencies to agree wider quality improvements reducing tracheostomy dislodgement risks, including methods of securing devices.

    Verbatim wording from the response

    “NHS England therefore propose initiating discussions with partner agencies including NCEPOD and Patient Safety Expert Groups (PSEGs) to agree how all parties can take forward wider quality improvements to reduce the risk of tracheostomy dislodgment, including, but not limited to, the best methods of securing these devices. We would be happy to keep you updated with progress as this work goes forward.”

    Source location

    2014-0259-Response-by-Department-of-Health
    Page 2 · response
    Published 5 June 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a generic medical device alert to UK hospitals highlighting risks and relevant changes to instructions for use.

    Verbatim wording from the response

    “• The MHRA issued a Generic Medical Device Alert (MDA/2012/062) on 11th September 2012 to all UK Hospitals highlighting the risks and changes to instructions for use for some silicone tracheostomy tubes. A copy of MDA/2012/062 is attached.”

    Source location

    2014-0259-Response-by-Department-of-Health
    Page 4 · response
    Published 5 June 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A ban on Velcro tracheostomy holders was not considered appropriate because either fastening system may create risks and unintended harms.

    Verbatim wording from the response

    “NHS England has considered whether it is safe and realistic to ban the use of Velcro to secure tracheostomies. A wider review of NRLS data and clinical practice suggests there are risks as well as benefits in using either fastening system, and that a ban on Velcro might introduce new unintended risks. It might also not be considered acceptable by some patients and carers.”

    Source location

    2014-0259-Response-by-Department-of-Health
    Page 2 · response
    Published 5 June 2014

    Open published response
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Data last updated 7 September 2026