Concerns raised 2
Inadequate evaluation and feedback before wholesale replacement of drainage tubes View source Lack of recognition of the need to aspirate the tube View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Medicines and Healthcare products Regulatory Agency University Hospitals of North Midlands NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
University Hospitals of North Midlands NHS Trust
Use the new equipment-evaluation proforma during initial trials to collect user feedback, with assistance from the Specialist Nurse.
View source
Medicines and Healthcare products Regulatory Agency
Write to UK nasogastric tube manufacturers about ENFit connector risks and request risk-assessment updates and, where applicable, corrective action, revised instructions and staff training.
View source
Medicines and Healthcare products Regulatory Agency
Contact BAPEN and NNNG to raise awareness of the nasogastric tube safety issue.
View source
University Hospitals of North Midlands NHS Trust
Review and update the LocSSIP for nasogastric and orogastric tube insertion to include troubleshooting guidance on tube aspiration.
View source
University Hospitals of North Midlands NHS Trust
Provide nasogastric and orogastric tube aspiration troubleshooting guidance in nursing and medical clinical guidelines.
View source
University Hospitals of North Midlands NHS Trust
Update e-learning for nasogastric and orogastric tube insertion and management to include aspiration troubleshooting, competency assessment and self-assessment.
View source See 3 more actions
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AI-generated summary
Peter John Hussey · 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
Peter John Hussey died after post-surgical complications following reversal of an ileostomy. A carefeed 14F nasogastric tube inadequately drained his stomach, allowing vomiting and contributing to aspiration pneumonia. Concerns included insufficient product description and staff training, inadequate evaluation of the tube, and failure to recognise poor drainage and consider alternative treatment or escalation.
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 Inadequate evaluation and feedback before wholesale replacement of 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 14Fr feeding and drainage tube . Feedback was generally difficult to obtain .
” Source location Peter John Hussey · 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 recognition of the need to aspirate the tube
Wider context from the report “(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining. There was no general recognition of the need to aspirate the tube .
” Source location Peter John Hussey · Prevention of Future Deaths report
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 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
Open published response
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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 Write to UK nasogastric tube manufacturers about ENFit connector risks and request risk-assessment updates and, where applicable, corrective action, revised instructions and staff training.
Verbatim wording from the response “In relation to concerns 2, 6 and 7, we will continue to collaborate with NHS England and Improvement on the best way to address this issue, such as raising awareness on the Medical Devices Safety Officers’ (MDSO) network. We will write to UK manufacturers of nasogastric tubes to advise them of the risk associated with the use of the ISO standard ENFit connector in aspiration/decompression situations and ask them to update their risk assessment, if not already done. We will advise that, where applicable, they should conduct a Field Safety Corrective Action (FSCA) and update their IFU, ensuring that their staff are fully trained in the changes so that they can provide advice to clinicians, where necessary. This action will be completed within 1 month.” Source location 2021-0115-Response-from-MHRA_Published
Open published response
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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 Contact BAPEN and NNNG to raise awareness of the nasogastric tube safety issue.
Verbatim wording from the response “In addition, we have contacted the British Association for Parenteral and Enteral Nutrition (BAPEN) and the National Nurses Nutrition Group (NNNG) to raise further awareness of this issue.” Source location 2021-0115-Response-from-MHRA_Published
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 Review and update the LocSSIP for nasogastric and orogastric tube insertion to include troubleshooting guidance on tube aspiration.
Verbatim wording from the response “The Trust Nasogastric Working Group, chaired by the Lead Nurse for Quality and Safety, have overseen a focused piece of work to review and update the Local Safety Standards for Invasive Procedure (LocSSIP) – Insertion of Nasogastric / Orogastric Tubes, to include ‘troubleshooting’ guidance regarding aspiration of nasogastric/orogastric tubes inserted for the purpose of drainage. Troubleshooting guidance will also be provided in both nursing and medical clinical guidelines.” Source location Response-from-Royal-Stoke-University-Hospital_Published
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 Provide nasogastric and orogastric tube aspiration troubleshooting guidance in nursing and medical clinical guidelines.
Verbatim wording from the response “The Trust Nasogastric Working Group, chaired by the Lead Nurse for Quality and Safety, have overseen a focused piece of work to review and update the Local Safety Standards for Invasive Procedure (LocSSIP) – Insertion of Nasogastric / Orogastric Tubes, to include ‘troubleshooting’ guidance regarding aspiration of nasogastric/orogastric tubes inserted for the purpose of drainage. Troubleshooting guidance will also be provided in both nursing and medical clinical guidelines.” Source location Response-from-Royal-Stoke-University-Hospital_Published
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 e-learning for nasogastric and orogastric tube insertion and management to include aspiration troubleshooting, competency assessment and self-assessment.
Verbatim wording from the response “The Trust e-learning training package for the insertion and on-going management of Nasogastric/Orogastric tubes has also been updated to include ‘troubleshooting’ guidance on aspiration of Nasogastric/Orogastric tubes and includes the development of a competency and self-assessment document; this will ensure that all registrants involved in the management of Nasogastric/Orogastric tubes are competent to do so.” Source location Response-from-Royal-Stoke-University-Hospital_Published
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 Concerns about hospital tube evaluation, clinical response, and root-cause-analysis training are addressed by a separate NHS England and Improvement response.
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 2021-0115-Response-from-MHRA_Published
Open published response
5 Jan 2021 Hariharan Harichandra · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to record severe adverse reactions to Naso-Gastric tube insertion View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Hariharan Harichandra · 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
Hariharan Harichandra, a 65-year-old man, fell from an electric wheelchair in hospital on 5 December 2019, sustaining a neck fracture, and died at The Royal Free Hospital on 19 December 2019. The concerns included errors in reporting and reviewing the CT scan, incomplete falls assessment, insufficient consideration of wheelchair safety equipment and spinal condition, and failure to record a severe adverse reaction to a naso-gastric 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 Failure to record severe adverse reactions to Naso-Gastric tube insertion
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion , future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” Source location Hariharan Harichandra · Prevention of Future Deaths report
Open source report
19 Dec 2019 Colin Beaumont · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 1
Failure to correctly place nasogastric tubes View source
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AI-generated summary
Colin Beaumont · 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
Colin Beaumont was the subject of an investigation into his death, which concluded at an inquest resulting in a Narrative Verdict. The report raised concern that a nasogastric tube was misplaced twice, leading to a pneumothorax that directly contributed to his death.
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 correctly place nasogastric tubes
Wider context from the report “(1) the fact that a Naso Gastric tube was misplaced twice in the same patient leading to a pneumothorax which directly contributed to death
” Source location Colin Beaumont · 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 Amend the nasogastric tube insertion policy to require alternative-feeding review and renewed risk discussions after repeated failed or misplaced insertions.
Verbatim wording from the response “Whether the Trust policy for Nasogastric Tube Insertion was appropriate and whether, as a result of this case, it should be amended in any way.” Source location 2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Open published response
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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 Explore sourcing an e-learning nasogastric tube refresher module with the learning and development team.
Verbatim wording from the response “Whether staff training in Nasogastric Insertion is appropriate.” Source location 2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
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 nasogastric tube procedure was clinically appropriate, with pneumothorax recognised as a small inherent risk.
Verbatim wording from the response “Interventions of this type are not undertaken lightly as there are recognised associated risks including that of pneumothorax, which Mr Beaumont unfortunately experienced. Nasogastric feeding tubes are passed to prevent malnutrition and so help the patient recover from their illness. The inherent mortality risk of malnutrition is balanced against the, often lesser, risks associated with the inserting of a nasogastric tube. In this case Mr Beaumont’s difficulty in swallowing was felt to be more likely a result of his infection from pneumonia rather than his stroke and so any feeding tube was likely to be short term in duration. Ensuring that Mr Beaumont had sufficient nutrition would also be essential in allowing him to fight the infection and recover to his previous level of health.” Source location 2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
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 Staff training was not a factor in the events because the staff involved were competent and followed current policy.
Verbatim wording from the response “Whether staff training in Nasogastric Insertion is appropriate.” Source location 2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
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 No further action is proposed regarding staff competency because both practitioners were trained, competent and followed current policy.
Verbatim wording from the response “Whether staff were suitably trained and competent to undertake the Nasogastric Tube Insertion.” Source location 2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Open published response
17 Dec 2019 Lewis Victor Mendelson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Helen Whatley MP Stockport Borough Council
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AI-generated summary
Lewis Victor Mendelson · 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
Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.
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 Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit
Wider context from the report “2. He was treated in hospital with no IMCA in place or formal best interests meeting taking place. As a result it was unclear if the treating physicians understood the complexity of his learning disability and communication issues that flowed from his disability. The inquest heard that repeated attempts were made to insert a nasogastric tube causing him great distress and where there was limited evidence that it would be beneficial ;
” Source location Lewis Victor Mendelson · 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 Medical treatment decisions fall outside the Council’s responsibility, so it cannot comment on the individual’s hospital treatment.
Verbatim wording from the response “This response solely addresses the concerns under paragraph 1, “The MATTER OF CONCERN”. Stockport Metropolitan Borough Council are unable to comment in respect of paragraph 2 which refers to the individual’s hospital treatment as, in accordance with the Mental Capacity Act 2005, the decision maker for best interest decisions in relation to medical treatment had been the NHS Trust. The arrangement of an IMCA and formal best interests meeting had been the responsibility of the Trust as this had concerned medical decisions. In this instance the NHS Trust would have been under a duty to consult with Stockport Council as stated in the Mental Capacity Act “...anyone engaged in caring for the person or interested in his welfare...”. Ultimately, if the matter had gone to the Court of Protection, the NHS Trust would have been the applicant.” Source location 2019-0434-Response-from-Stockport-Council_Redacted
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 The local NHS is expected to reflect on the LeDeR findings and address identified local failings in care.
Verbatim wording from the response “The Programme systematically reviews the deaths of all people with a learning disability, aged four years and above, that are notified to it. The Programme enables a detailed picture to be built of key improvements that are needed both locally and at a national level, to reduce the inequality in life expectancy between people with a learning disability, and those without.” Source location 2019-0434-Response-from-the-Department-of-Health-and-Pensions-1
Open published response
4 Apr 2017 Robert John Owens · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3
Lack of clear guidance for nasogastric tube practice in the ITU setting View source Failure to perform PH testing after nasogastric tube insertion View source Failure to follow the nasogastric tube insertion checklist View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Robert John Owens · 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
Robert John Owens was admitted to hospital with back pain, developed acute kidney injury and respiratory failure, and was transferred to intensive care. After a naso-gastric tube was replaced and incorrectly positioned, feeding commenced; he became unwell and died on 16 December 2016. The report identified concerns about outdated guidance, failure to follow national pH-testing and x-ray guidance, and inconsistent use of insertion checklists and procedures.
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 clear guidance for nasogastric tube practice in the ITU setting
Wider context from the report “(3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not being followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment.
” Source location Robert John Owens · 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 perform PH testing after nasogastric tube insertion
Wider context from the report “(2) Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and x-raying of a patient after the insertion of a tube, these guidelines were never followed . The evidence revealed that it is common practice within the Health Board only to x-ray and not to follow the National Guidance of PH testing .
” Source location Robert John Owens · 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 follow the nasogastric tube insertion checklist
Wider context from the report “(3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not being followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment.
” Source location Robert John Owens · Prevention of Future Deaths report
Open source report
18 Jan 2017 Michael Parke · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1
Failure to roll out training to all staff who need it View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Michael Parke · 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
Michael Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.
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 roll out training to all staff who need it
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Michael Parke · 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 The principal patient-safety problem is inconsistent implementation, rather than unavailable guidance or ineffective current placement checks.
Verbatim wording from the response “In conclusion, I am advised that the challenge around improving patient safety in this area is not the availability or appropriateness of national guidance, or the effectiveness of current placement checks but rather their implementation. By ensuring medical and nursing staff have the right competencies to undertake procedures relating to nasogastric tube placement, NHS Trusts can ensure that patient harm and deaths are avoided.” Source location 2017-0024-Response
Open published response
18 Jan 2017 Amanda Coulthard · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 8
Failure of staff to apply the nasogastric tube policy View source Failure of staff to follow good practice for nasogastric tube use View source Failure of staff to read the nasogastric tube policy View source
Lack of staff awareness of the nasogastric tube policy View source Failure to maintain accurate cross-references in the nasogastric tube policy View source Nasogastric tube policy becoming difficult for practitioners to absorb View source Failure to fully implement the 2011 NPSA Alert on nasogastric tubes View source Lack of ward-level systems to ensure compliance with the nasogastric tube policy View source See 5 more concerns
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Amanda Coulthard · 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
Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.
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 staff to apply the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 of staff to follow good practice for nasogastric tube use
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 of staff to read the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 staff awareness of the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 maintain accurate cross-references in the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions , and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 Nasogastric tube policy becoming difficult for practitioners to absorb
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 fully implement the 2011 NPSA Alert on nasogastric tubes
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 ward-level systems to ensure compliance with the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Source location Amanda Coulthard · 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 Include delivery-plan progress and compliance with the updated Nasogastric Tube Policy in the 2017/18 Internal Audit Plan for independent Board assurance.
Verbatim wording from the response “Attached to this letter is a report summarising the action we have taken against the five specific actions in your Regulation 28 Notice. We have also summarised additional actions that we have identified and will implement over the next 12 months. Progress against the delivery of this plan and compliance with the updated Nasogastric Tube Policy will be included in the Trust’s Internal Audit Plan for 2017/18. This is to ensure that independent assurance on the delivery of the plan and implementation of the policy can be provided to the Trust Board.” Source location 2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust
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 The principal patient-safety problem is inconsistent implementation, rather than unavailable guidance or ineffective current placement checks.
Verbatim wording from the response “In conclusion, I am advised that the challenge around improving patient safety in this area is not the availability or appropriateness of national guidance, or the effectiveness of current placement checks but rather their implementation. By ensuring medical and nursing staff have the right competencies to undertake procedures relating to nasogastric tube placement, NHS Trusts can ensure that patient harm and deaths are avoided.” Source location 2017-0024-Response
Open published response
16 Dec 2014 John Charles Leyin · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to check whether staff are up to date in training for carrying out procedures View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Charles Leyin · 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
John Charles Leyin was admitted to Basildon Hospital after suffering a stroke and later died after difficulties with feeding arrangements, including a nasogastric tube being placed into his lung. The concerns included failures to disseminate relevant policy and guidance, weaknesses in training systems, inadequate checks of staff training, and uncertainty about the number of trained staff available for such procedures.
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 check whether staff are up to date in training for carrying out procedures
Wider context from the report “(3) Checks were not made as to whether or not staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube .
” Source location John Charles Leyin · 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 Strengthen nasogastric-tube competence training through designated trainers and assessors, structured competency stages, verified records and monthly compliance reporting.
Verbatim wording from the response “The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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 Senior Ward Sisters are responsible for maintaining local staff training records, supported by monthly competence-compliance reports as a fallback.
Verbatim wording from the response “It was clear following the incident that additional checks were required to ensure compliance with training. As the manager responsible for the team the onus is on the Senior Ward Sisters to maintain their records locally. However, the monthly competence compliance report is circulated to the Heads of Nursing and Senior Ward Sisters as a fall back mechanism and enables them to keep track of their staff records as well. Paper copies of the nurses’ Competency Framework are kept in staff records on the ward.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
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 The Trust considers its training, compliance reporting and locally held records sufficient to mitigate the risk of a similar incident.
Verbatim wording from the response “I hope that this has provided you with sufficient assurance that we have undertaken a series of actions to mitigate any risk of a similar incident happening again. Further assurance can be provided through training records that are held locally at the Trust.” Source location 2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Open published response
8 Apr 2014 Frederick William Hall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of skill and training in passing NG tubes View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
Frederick William Hall · 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
Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.
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 skill and training in passing NG tubes
Wider context from the report “1. There seemed to be a lack of skill and/or training amongst the general nursing and medical staff in the passing of NG Tubes . However, it was noted that the ITU staff regularly insert such tubes and one would question whether there should be an agreed procedure whereby they should be asked to undertake this task throughout the hospital.
” Source location Frederick William Hall · Prevention of Future Deaths report
Open source report
14 Oct 2013 Frederick Davidson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3
Inadequate recording of nasogastric tube placement View source Feeding via nasogastric tube before completion of full checks View source Failure to record nasogastric tube feeding authorisation View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring 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
Frederick Davidson · 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
Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.
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 Inadequate recording of nasogastric tube placement
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Source location Frederick Davidson · 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 Feeding via nasogastric tube before completion of full checks
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Source location Frederick Davidson · 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 record nasogastric tube feeding authorisation
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Source location Frederick Davidson · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.