Recurring concern

Failure to reliably investigate suspected bowel perforation

First to latest report 7 Mar 2022 — 9 Feb 2026

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
0

What this concern includes

Includes failures to maintain or investigate suspected bowel perforation, including abandoning the differential diagnosis without full investigation and failing to consider altered anatomy or investigate potential perforation after nasogastric-tube insertion complications.

What is not included
  • Excludes general diagnostic delays or incomplete investigations where suspected bowel perforation is not a material concern.
  • Excludes nasogastric-tube insertion, altered-anatomy and other procedural failures where no suspected bowel-perforation investigation issue is identified.
  • Excludes bowel obstruction, gastrointestinal bleeding and other abdominal conditions unless the assertion specifically concerns suspected bowel perforation.
  • Excludes treatment or surgical-management failures after suspected bowel perforation has been adequately investigated.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Northumberland

    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.

    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 consider altered gastric anatomy and investigate potential perforation when complications arise

    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
    Page 2 · concerns

    Open source report

  2. Northumberland

    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

    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
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    ARTHUR FREDERICK 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

    Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

    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 account for the limited sensitivity of upright chest X-rays when excluding perforation

    Wider context from the report

    “2. The recognised first line of enquiry was an upright chest X-ray. What is known about upright chest Xray’s is that they are known to miss a number of perforations. This was used to exclude the possibility of perforation when it is a known limited diagnostic tool that can miss from 20% of perforations to 50% of perforations (see literature). ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to undertake second-line investigation of suspected perforation

    Wider context from the report

    “3. Second line of enquiry (endoscopy or CTPA) was not undertaken. ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete investigation of suspected bowel perforation

    Wider context from the report

    “1. On the 1st February 2018 the differential diagnosis of bowel perforation was abandoned without full investigation. ”

    Source location

    ARTHUR FREDERICK HALL · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026