9 Feb 2026 Ellen Victoria Floyd Taylor · Prevention of Future Deaths report Northumberland
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Concerns raised 2
Failure to routinely recognise previous gastric surgery during nasogastric tube insertion View source Lack of guidelines for nasogastric tube insertion after previous gastric surgery View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ellen Victoria Floyd Taylor · 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
Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, resulting in acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the report raises concerns about the lack of guidance and wider NHS risk regarding nasogastric tube insertion in patients with previous gastric surgery.
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× 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 routinely recognise previous gastric surgery during nasogastric tube insertion
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
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 guidelines for nasogastric tube insertion after previous gastric surgery
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery .
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline . Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS Trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
Open source report
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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 Support provider organisations to adopt and safely implement electronic patient records, including improved interoperability and information sharing.
Verbatim wording from the response “NHS England has developed and led for the last 5 years a Frontline Digitisation (FD) Programme, which has supported provider organisations across England to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Shared Care Records Programme to support wider access to relevant patient information.
Verbatim wording from the response “NHS England is aware of the challenge in sharing medical records and results within organisations and recognises the variability between areas using different technologies. The FD programme continues to work across the health and care system to support greater integration and awareness of record sharing between providers. NHS England is also working with the Shared Care Records Programme which supports wider access to relevant patient information.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish a ten-year healthcare plan committing to a single, secure and authoritative patient record.
Verbatim wording from the response “Developing this further NHS England and the Department of Health and Social Care published the Fit for the future: 10 Year Plan for England, which sets out the government’s plan for healthcare in England over the next 10 years. It also sets out a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record – to enable more coordinated, personalised and predictive care.’” Source location Response from NHS England
Open published response
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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 Responsibility for clinical guidance on nasogastric tube insertion sits with NICE, which should address concerns about national guidance.
Verbatim wording from the response “The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE). We would advise the Coroner to contact NICE directly to address concerns regarding the guidance.” Source location Response from NHS England
Open published response
9 Feb 2026 Ellen Victoria Floyd Taylor · Prevention of Future Deaths report Northumberland
View report summary
Concerns raised 3
Failure to routinely recognise and consider previous gastric surgery during nasogastric tube insertion and subsequent complications View source Lack of nasogastric tube insertion guidelines for patients with previous gastric surgery View source Delays in investigating potential perforation after nasogastric tube complications View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ellen Victoria Floyd Taylor · 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
Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, leading to acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the perforation was not initially recognised. The report identifies concerns about the absence of guidance for inserting nasogastric tubes in patients with previous gastric surgery and a wider risk to patients nationally.
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 routinely recognise and consider previous gastric surgery during nasogastric tube insertion and subsequent complications
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion .
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
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 nasogastric tube insertion guidelines for patients with previous gastric surgery
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery .
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline . Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
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 Delays in investigating potential perforation after nasogastric tube complications
Wider context from the report “(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.
On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.
The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially .
(2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.
The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion.
Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.
Whilst the local NHS Traut have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.
” Source location Ellen Victoria Floyd Taylor · Prevention of Future Deaths report
Open source report
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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 Responsibility for clinical guidance lies with NICE, so concerns about national nasogastric tube guidance should be directed to NICE.
Verbatim wording from the response “The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE). We would advise the Coroner to contact NICE directly to address concerns regarding the guidance.” Source location Response from NHS England
Open published response
9 Jan 2025 David Vincent Tighe · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 2
Unavailability of Ryles tube repeat-position-check records View source Absence of a specific policy for management of Ryles tubes View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Vincent Tighe · 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 Vincent Tighe, a 59-year-old man receiving chemotherapy for cancer, was admitted to hospital with chemotherapy-induced enterocolitis. During his treatment, bile aspiration occurred after insufficient monitoring and displacement of a Ryles tube, contributing to bronchopneumonia and sepsis, from which he died. The principal concerns were the absence of a specific Ryles tube policy and the use of a narrowly focused structured review that could miss care or procedural problems.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of Ryles tube repeat-position-check records
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice.
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed .
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment.
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
” Source location David Vincent Tighe · Prevention of Future Deaths report
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 Absence of a specific policy for management of Ryles tubes
Wider context from the report “Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes , and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (“NG feeding tube policy”), which provided limited advice .
Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death.
Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but no several staff were unaware of such a document existing for Ryles tubes, and no such Ryles tubes records were ever disclosed.
Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring.
At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023.
It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required.
The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure.
Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of medical records across five different areas, undertaken in a highly pressured environment.
The Structured Review consequently overlooked considering several issues including:
(i) missing bile drainage entries.
(ii) missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021).
(iii) the absence of Repeat Position Checks for the Ryles tube.
(iv) the absence of any written record of family concerns that were raised with a ward sister.
Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review.
That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance.
Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
” Source location David Vincent Tighe · Prevention of Future Deaths report
Open source report
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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 Review current practice and develop a Trust-wide policy for managing Ryles tubes used for aspiration drainage.
Verbatim wording from the response “There is no nationally recognised policy for wide bore nasogastric (Ryles) tubes for aspiration drainage. The existing OUH policy is for nasogastric (NG) tubes when used for feeding. Current practice for insertion of a wide bore tube is based on the Royal Marsden manual of clinical and cancer nursing procedures. Only one of the 9 similar Trusts who we approached has a policy which is virtually identical to the Royal Marsden manual.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present and publish the Ryles tube policy and communicate it to all staff through a Trust-wide safety message.
Verbatim wording from the response “The Oncology Matron has set up a working group to review current practice, evaluate external resources and produce a Trust wide policy. The policy will set out the Trust standards for managing patients with Ryles Tubes for aspiration drainage. The working group includes nursing and medical staff across the organisation including anaesthetics, surgery, oncology and gastroenterology representatives. The first meeting was held on 3 February 2025. The policy will be presented to the OUH Clinical Policy Group by April 2025 and a Trust wide safety message will be communicated to all staff which will include the link to this policy. The publication of the policy will be followed by training of the appropriate staff through ward-based learning delivered by clinical educators.” Source location Response from Oxfordshire University Hospitals NHS Foundation Trust
Open published response
7 Dec 2023 Sarah CHAPPELL · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to maintain timely effective nasogastric tube decompression View source Failure to escalate unsuccessful nasogastric tube placement to appropriate medical expertise View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sarah CHAPPELL · 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
Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain timely effective nasogastric tube decompression
Wider context from the report “5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate . The tube in situ that was operating effectively was removed approximately ten days before her death . Her abdomen became extremely distended.
A further tube placement was not attempted until the day before she died . When this proved beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon.
By then, two experienced doctors were unable to insert a tube and, as they were attending her (with her mother present), their patient suffered a massive aspiration and died shortly afterwards.
I was told at inquest that if the nasogastric tube had been passed at an earlier point, this would have been done successfully and the fatal cardiac arrest would have been avoided.
” Source location Sarah CHAPPELL · Prevention of Future Deaths report
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 escalate unsuccessful nasogastric tube placement to appropriate medical expertise
Wider context from the report “5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate. The tube in situ that was operating effectively was removed approximately ten days before her death. Her abdomen became extremely distended.
A further tube placement was not attempted until the day before she died. When this proved beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon .
By then, two experienced doctors were unable to insert a tube and, as they were attending her (with her mother present), their patient suffered a massive aspiration and died shortly afterwards.
I was told at inquest that if the nasogastric tube had been passed at an earlier point, this would have been done successfully and the fatal cardiac arrest would have been avoided.
” Source location Sarah CHAPPELL · Prevention of Future Deaths report
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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 nasogastric-tube policy to cover surgical drainage and escalation of difficult or unsuccessful tube placement.
Verbatim wording from the response “Ms Chappell was admitted to UCLH with a nasogastric (NG) tube from PRUH on 1st June 2023. The NG tube was removed on 10th June 2023 due to low drainage volume which is appropriate practice. A NG tube can be uncomfortable for patients and prolonged placement can cause inflammation of the oesophagus. We therefore remove them if they are not required. Following a scan on 22nd June there was a request for a new, larger NG to be inserted. Nasogastric tube insertion can be difficult and not predictable as to which in patients such insertion may succeed. However, we recognise there were multiple attempts to insert the larger NG tube and that there were failings in the escalation of a difficult NG tube insertion.” Source location Response from University College London Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation UCLH states the NG tube was removed appropriately because drainage was low, and that subsequent insertion was inherently difficult and unpredictable.
Verbatim wording from the response “Ms Chappell was admitted to UCLH with a nasogastric (NG) tube from PRUH on 1st June 2023. The NG tube was removed on 10th June 2023 due to low drainage volume which is appropriate practice. A NG tube can be uncomfortable for patients and prolonged placement can cause inflammation of the oesophagus. We therefore remove them if they are not required. Following a scan on 22nd June there was a request for a new, larger NG to be inserted. Nasogastric tube insertion can be difficult and not predictable as to which in patients such insertion may succeed. However, we recognise there were multiple attempts to insert the larger NG tube and that there were failings in the escalation of a difficult NG tube insertion.” Source location Response from University College London Hospitals
Open published response
8 Aug 2023 Reginald Edwin Bourn · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5
Lack of national guidance for placement of nasogastric decompression tubes View source Lack of instructions for inserting and confirming placement of nasogastric decompression tubes View source Risk of nasogastric decompression tube misplacement into the lung View source
Failure to provide protocols for checking placement of nasogastric decompression tubes View source Lack of training for insertion of nasogastric decompression tubes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Reginald Edwin Bourn · 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
Reginald Edwin Bourn was admitted to hospital with an intestinal blockage and required a nasogastric decompression tube. The replacement tube was misplaced into his left lung, after which he aspirated gastrointestinal contents and died. The report raised concerns about the absence of national guidance, protocols and training for inserting and confirming the placement of nasogastric decompression tubes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of national guidance for placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes . However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes .
” Source location Reginald Edwin Bourn · Prevention of Future Deaths report
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 instructions for inserting and confirming placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither .
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Source location Reginald Edwin Bourn · Prevention of Future Deaths report
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 Risk of nasogastric decompression tube misplacement into the lung
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal .
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Source location Reginald Edwin Bourn · Prevention of Future Deaths report
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 protocols for checking placement of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed .
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes.
” Source location Reginald Edwin Bourn · Prevention of Future Deaths report
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 training for insertion of nasogastric decompression tubes
Wider context from the report “1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus.
2. Examples of nasogastric decompression tubes and nasogastric feeding tubes were provided in evidence. The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. Decompression tubes have neither.
3. The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal.
4. The clinicians who investigated the death could not find any nationally recognised protocols dealing with the use of, and training on the insertion of, nasogastric decompression tubes nor for checking whether they are appropriately placed.
5. The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents.
6. One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing.
7. It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes .
” Source location Reginald Edwin Bourn · Prevention of Future Deaths report
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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 Share the report with the topic selection and prioritisation team for consideration of guidance on nasogastric decompression.
Verbatim wording from the response “NICE has not published guidance on the management of small bowel obstruction, and so has not made recommendations on nasogastric decompression. Your report has been shared with our topic selection and prioritisation team to consider the need for NICE guidance in this area.” Source location Response from National Institute for Health and Care Excellence
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the HSIB and coroner reports with the guideline surveillance team to assess whether the nasogastric tube recommendation requires updating.
Verbatim wording from the response “Both the HSIB’s report on the placement of nasogastric tubes and your report concerning the death of Mr Bourn have been shared with NICE’s guideline surveillance team to see if an update to this recommendation is required.” Source location Response from National Institute for Health and Care Excellence
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review manufacturers’ instructions for use for nasogastric feeding and decompression tube placement.
Verbatim wording from the response “Following receipt of the Regulation 28 Report we have considered point two in the matters of concern: “Feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. The decompression tubes have neither”. We have reached out to the manufacturers of nasogastric tubing to confirm their primary intended use and to review their instructions for use (IFU) for both feeding and decompression tube placement.” Source location Response from Medicines and Healthcare Products Regulatory Agency
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with manufacturers to update instructions for use where the review identifies applicable changes.
Verbatim wording from the response “We expect to complete the initial review of the IFUs by 4 January 2024. Following this review, we will work with manufacturers to update their IFU where applicable. If updates are made, the MHRA is of the opinion that they should issue a Field Safety Notice (FSN) to highlight the changes to clinicians, and ensure that their staff are fully trained in the changes so that they can provide advice to clinicians where necessary.” Source location Response from Medicines and Healthcare Products Regulatory Agency
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Royal Marsden Manual guidance is considered sufficient, so NHS England would not routinely provide national guidance on nasogastric tube insertion.
Verbatim wording from the response “Whilst NHS England would not routinely provide national guidance on the insertion of nasogastric decompression tubes, there is existing national guidance in the form of the Royal Marsden Manual, who have particular expertise in this area. The manual has a section on ‘Insertion of a nasogastric drainage tube’ which contains background information and specific procedural guidance for the insertion and removal of these tubes, including around pH testing. This is aimed at clinical nursing staff who would routinely be the staff responsible for placing nasogastric tubes in patients. The Manual is a well-known guide for nurses to deliver clinically effective, patient-focused, and evidence-based care.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE is the statutory body responsible for developing and disseminating clinical guidance on nasogastric tube placement and confirmation.
Verbatim wording from the response “The National Institute of Health and Care Excellence (NICE) are the statutory body who lead on developing and disseminating clinical guidance and I note that you have also sent your Report to them. NHS England will carefully consider NICE’s response to you and any actions that may be required from us as a result.” Source location Response from NHS England
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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 MHRA is best placed to consider instructions for nasogastric decompression tubes as the UK regulator of medical devices.
Verbatim wording from the response “Instructions for nasogastric decompression tubes” Source location Response from National Institute for Health and Care Excellence
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A national training programme for nasogastric tube insertion falls outside NHS England’s remit.
Verbatim wording from the response “As to national training provisions around insertion of nasogastric tubes, I asked my colleagues from the national Workforce, Training and Education (WTE) Directorate at NHS England to consider your Report and the concerns raised. They advised that such a training programme would not come under NHS England’s remit. Individual NHS Trusts are responsible for the implementation of locally recommended practice and protocols, including the staffing and availability of workforce. You may wish to engage with Firmley Health NHS Foundation Trust for further information on their specific practice and protocols regarding placement of nasogastric tubes.” Source location Response from NHS England
Open published response
Concerns raised 1
Delays in inserting required NG tubes View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ann Pickering · 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
Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in inserting required NG tubes
Wider context from the report “During the inquest, evidence showed:-
1. There was a recognition on 17.2.21 by Kendray Hospital that NG tube feeding was required.
2. Barnsley Hospital did not initially feel transfer should take place to them and it was not until 23.6.21 that they accepted a transfer
3. Despite recognising an NG tube was required, one was not inserted until the 30.6.21
4. There was a lack of clear policies and procedure about how a patient under a section should be transferred and what documentation / resource should go with them.
” Source location Ann Pickering · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the existing nutrition policy and agree nutritional-support and nasogastric-tube insertion requirements for detained patients, including restraint situations.
Verbatim wording from the response “In addition to collaborative working between SWYPFT and BHNFT, a review of BHNFT’s existing nutrition policy and agreement on meeting a patient’s nutritional requirements particularly for detained patients, including where there is a need for restraint will be undertaken jointly.” Source location Response from NHS South West Yorkshire Partnership
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put in place a standard operating procedure with timescales for timely nutritional support and clear cross-Trust responsibilities.
Verbatim wording from the response “Nutritional support will be provided in a timely manner by staff from the respective Trusts being clear about their roles and responsibilities in their own organisations, and collectively so that delays do not arise. A standard operating procedure to clarify this along with clear timescales will be in place by 30 November 2022 (EXHIBIT 1).” Source location Response from NHS South West Yorkshire Partnership
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22 Feb 2022 VAN THAI TUYEN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of a unified approach to address ongoing use of misplaced nasogastric tubes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
VAN THAI TUYEN · 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
Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a unified approach to address ongoing use of misplaced nasogastric tubes
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes .
” Source location VAN THAI TUYEN · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to provide consistent nasogastric supplementary feeding when oral intake is insufficient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Catherine Jane Best · 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
Catherine Jane Best was pronounced dead on 23 June 2012 at Morriston Hospital after an anoxic brain injury caused by a cardiac arrest associated with malnourishment and sepsis. The report raised concerns that nasogastric feeding was removed despite poor oral intake and was not consistently reinstated, resulting in inadequate nutritional supplementation. The inquest concluded that there had been a failure to invoke nasogastric feeding sooner when oral intake was insufficient, although it could not be determined whether this would have prevented the cardiac arrest.
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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 consistent nasogastric supplementary feeding when oral intake is insufficient
Wider context from the report “During the course of the inquest it was apparent that the deceased was a complex and challenging patient and her appetite was poor. Although there were attempts to get her to eat, and alternatives offered, her calorific input remained poor. Up until the 17th of May Catherine was fed using a combination of nasogastric feeding and oral intake. After that date regular NG feeding was removed despite poor oral intake. There were instances where NG feeding were re-introduced after that date but it was not consistent and there was no explanation for the removal of regular NG feeding on the 17th of May at a time when her oral intake was not sufficient to provide the required nutrition.
Whilst encouraging Catherine to obtain her calories from oral intake was appropriate there was a regular pattern of her refusing her meals or eating less than the portions provided. There was a lack of documentary evidence verifying options and encouragement although assurances that this was being done was provided by way of oral evidence. I am concerned however that in cases involving difficult or challenging patients they may not be given adequate nourishment if the oral offering is refused or partly taken. This could result in situations where a patient's ability to recover is reduced due to insufficient nourishment. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.
1. There was an inadequate regime of supplemented feeding by way of nasogastric tube meaning that Kate was not receiving a consistent amount of calories per day to increase the chances of fighting infection. Kate was a challenging patient and it could not be guaranteed that Kate would always take her meals thus ensuring that her calorie intake was obtained orally.
” Source location Catherine Jane Best · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Screen every admitted patient for nutritional risk using the All-Wales tool and monitor intake through Food and Fluid Charts.
Verbatim wording from the response “The All-Wales Hospital Nutrition Care Pathway Protocol was adopted within the predecessor organisations of SBUHB in 2008. As part of this pathway, the Adult Nutrition Risk Screening Tool (WAASP) was used for the identification of nutritional risk. This tool is used for every patient on admission to ensure the early identification and intervention for patients at risk or presenting with malnutrition or dehydration. The pathway also mandated the use of All Wales Food and Fluid Charts which monitor patient's oral food and fluid intake to identify those patients at risk of malnutrition and to aid referral to specialist teams such as dietetics or speech and language therapists to identify poor intakes.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the All-Wales inpatient nutrition risk screening tool and provide supporting training and e-learning, with compliance monitored through the Steering Committee.
Verbatim wording from the response “In 2019, the “All Wales in Patient Nutrition Risk Screening Tool” was adopted within SBUHB following the Welsh Health Circular (2019) 026. The tool includes additional guidance on referral to Nutrition and Dietetic Services, including for those who require enteral tube feeding or where clinical judgment indicates that there are additional nutritional concerns. The implementation of the All Wales Tool was supported by additional training sessions provided by the Nutrition & Dietetic Service and the launch of an e-learning module. Compliance with the e-learning module will be monitored through the Nutrition and Hydration Steering Committee.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver nutrition-risk, nutritional-care-pathway and enteral-feeding training through New Registrant and Nurse Induction programmes.
Verbatim wording from the response “The Nutrition and Dietetic Service delivers training on the identification of nutritional risk, nutritional care pathways and enteral tube feeding as part of the New Registrant and Nurse Induction programmes.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver nutrition and enteral or parenteral nutrition training to F1 and F2 medical staff as ongoing professional development.
Verbatim wording from the response “The Nutrition and Dietetic Service deliver training sessions on nutrition and enteral/parenteral nutrition for F1 and F2 medical staff as part of their ongoing professional development.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update refeeding-syndrome and out-of-hours enteral-feeding guidance to reflect national recommendations and clinical practice.
Verbatim wording from the response “The Swansea Bay University Health Board Guidance on the Management of Refeeding Syndrome and the Standard Out of Hours Enteral Feeding Regime have been reviewed three yearly since they were published in 2011.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update eating-disorder nutritional-management and enteral-feeding guidance to reflect MARSIPAN recommendations and review it every three years.
Verbatim wording from the response “Additional SBUHB Guidance on the Nutritional Management of Patients with Eating Disorders during acute admissions and a Standard Enteral Feeding Regime for patients with Eating Disorders were published in June 2012. This guidance has been updated to reflect changes in the recommendations of the ‘MARSIPAN working group² and is reviewed every 3 years.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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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 NG-tube insertion and management policy to include clinical decision-making guidance and deliver competency-based implementation training.
Verbatim wording from the response “The Health Board policy on the Insertion and Management of NG Feeding Tubes was updated in 2018 and includes reference to the clinical decision making process to support NG tube feeding.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a high-nutritional-risk care plan for periods of low staffing or staff redeployment.
Verbatim wording from the response “During the COVID 19 pandemic a Care Plan for the Management of High Nutritional Risk was implemented to support areas in the event of low staffing levels or staff redeployment.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing the high-nutritional-risk care plan with colleagues to support areas experiencing staff shortages.
Verbatim wording from the response “The Nutrition and Dietetic service are continuing to work with colleagues to develop this care plan to support areas of staff shortage.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply Clinical Standards for Inpatient Nutritional Support, including consideration of enteral nutrition when oral intake is insufficient.
Verbatim wording from the response “The Clinical Standards for Inpatient Nutritional Support have been adopted by the Health Board since 2017. They include reference to consideration of enteral nutrition for patients who are unable to meet their nutritional requirements orally. An audit of compliance to the standards is undertaken every 2 years by the Nutrition and Dietetic Service with the next planned audit in autumn 2021. The results and Action Plan for improvement are agreed with the Nutrition and Dietetic Service Clinical Governance meetings.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with inpatient nutritional-support standards every two years and agree improvement actions through clinical governance meetings.
Verbatim wording from the response “The Clinical Standards for Inpatient Nutritional Support have been adopted by the Health Board since 2017. They include reference to consideration of enteral nutrition for patients who are unable to meet their nutritional requirements orally. An audit of compliance to the standards is undertaken every 2 years by the Nutrition and Dietetic Service with the next planned audit in autumn 2021. The results and Action Plan for improvement are agreed with the Nutrition and Dietetic Service Clinical Governance meetings.” Source location 2021-0244-Response-from-Swansea-Bay-University-Health-Board_Published
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12 Jul 2021 Stephen Francis WALKER · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to document whether nasogastric tube placement was offered and declined View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen Francis WALKER · 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
Stephen Francis Walker was admitted for an ileostomy reversal and developed vomiting and severe illness several days later. A nasogastric tube was not placed until that evening, and he died the following day after admission to intensive care. Concerns included delayed assessment and treatment, inadequate or missing records of clinical reviews and consent, and confusing medical records; the inquest found that earlier tube placement would have improved his chance of survival.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to document whether nasogastric tube placement was offered and declined
Wider context from the report “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.
However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed.
2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this .
3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased.
” Source location Stephen Francis WALKER · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the electronic patient information system to provide clinicians with contemporaneous clinical records.
Verbatim wording from the response “I would like to inform you that the Royal Free Hospital has recently launched a new electronic patient information system called EPR, which allows our clinical teams to have access to contemporaneous clinical records. We are confident that this will support improvements in both documentation and communication.” Source location 2021-0254-Response-from-Royal-Free-Hospital_Published
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Concerns raised 1
Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen James Oakes · 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
Stephen James Oakes, aged 59, died in hospital on 23 December 2017 after a carefeed 14F nasogastric tube inadequately drained stomach contents, allowing vomit to pass the tube and leading to aspiration pneumonia in the context of metastatic bronchial carcinoma and small bowel obstruction. The principal concerns included inadequate product description and staff training, insufficient hospital evaluation of the tube, failure to recognise inadequate drainage or consider alternatives, and possible wider product-labelling problems.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes
Wider context from the report “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14F feeding and drainage tube . Feedback was generally difficult to obtain .
” Source location Stephen James Oakes · Prevention of Future Deaths report
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the new equipment-evaluation proforma during initial trials to collect user feedback, with assistance from the Specialist Nurse.
Verbatim wording from the response “Matters relating to the inquest touching upon the deaths of Mr Hussey and Mr Oakes were discussed at the Medical Device Strategy Committee (MDSC) and as a consequence, a new proforma for evaluating equipment has been designed and will be used to collect feedback from users during the initial trial period. As indicated at the inquest, the recently appointed Specialist Nurse will assist in gathering this data.” Source location Response-from-Royal-Stoke-University-Hospital_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and Improvement is responsible for responding to concerns about Hospital Trust evaluation, nursing practice, and root-cause-analysis training.
Verbatim wording from the response “We understand from NHS England and Improvement that a separate response has been provided to yourself covering points 3, 4 and 5.” Source location 2021-0114-Response-from-MHRA_Published
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns concerning local hospital practice should be addressed by the relevant Local Trust.
Verbatim wording from the response “Further to the email sent on 10 June 2021 from ████████, Business Manager in my Quality Strategy Team, I am conscious that the majority of your concerns would be better placed with the Local Trust, to whom you have sent the report, and colleagues at the Medicines and Healthcare products Regulatory Agency (MHRA). The Small Bore Connector Group, which you refer to in the addressees of the report was discontinued some time ago. On that basis I have shared the report with colleagues at MHRA who I understand will address the concerns relevant to their area of work.” Source location 2021-0114-Response-from-NHS-England-NHS-Improvement_Published
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Includes failures of controls specifically dedicated to safe Ryles or nasogastric tube management, including policies and guidance, staff competence, insertion, position verification and repeat checks, authorisation before feeding, ongoing monitoring, timely replacement or escalation, and associated records where they support safe tube care.
