Recurring concern
Unreliable post-operative PEG care and complication management
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Request correctionFirst reported 11 Sep 2015•Latest report 4 Aug 2023
What this concern includes
Includes failures in dedicated PEG care and post-operative PEG management, including recognition and escalation of peritonitis or other PEG complications, adherence to PEG-related guidance, staff competence, feeding-position and mobilisation controls, and required equipment or monitoring safeguards.
Not included
- Excludes generic post-operative care, sepsis, aspiration or clinical-deterioration failures where PEG care is not the material unsafe condition.
- Excludes failures in PEG insertion, placement or procedural competence when no post-operative or feeding-care deficiency is identified.
- Excludes general nutrition, hydration, moving-and-handling or equipment failures unless they directly impair safe PEG feeding or post-operative PEG care.
- Excludes treatment of a PEG complication after it has been reliably recognised and escalated.
- Reports
- 5
- Individual concerns
- 10
- Date range
- 2015–2023
- Stated actions
- 4
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised2
Failure to escalate post-PEG patient concerns to a senior doctor for consideration of possible bleeding
Failure to closely monitor deteriorating patients after PEG insertion
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Lack of staff knowledge about post-operative PEG risks and contraindications
Failure to ensure peritonitis risk is identifiable after PEG surgery
Failure to place required PEG warning labels in patient notes
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Issue a staff Red Alert reinforcing vigilance for post-operative peritonitis and guidance on PEG-tube care.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to assess the suitability and volume of continued PEG feeding in the community
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Stated by Care Quality Commission
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Position
CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.
Stated by Care Quality Commission -
Position
The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to follow written guidance for post-operative abdominal pain after PEG insertion
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Rewrite post-PEG care guidance and provide it to all relevant clinicians, including warning-sticker requirements.
Stated by Queen Victoria Hospital NHS Foundation Trust -
Action
Monitor the trust’s prospective PEG audit through routine engagement, including adherence to policy and timely escalation of deterioration.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Stated by Department of Health and Social Care
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Concerns raised3
Lack of care-staff training and competence in PEG feeding, including resident mobility, handling and feed controls
Failure to record and escalate incidents involving PEG feeding
Failure of the bed remote control needed to adjust the bed position during PEG feeding
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026