Recurring concern

Unreliable post-operative PEG care and complication management

First to latest report 11 Sep 2015 — 4 Aug 2023

Reports that mention this concern
5
Times this concern has been raised
10
Stated actions linked to this concern
4

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.

What is 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 and published responses 5 reports

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

  1. Milton Keynes

    AI-generated summary

    Harry Arthur STOBIE · 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

    Harry Arthur STOBIE suffered a stroke, underwent thrombectomy and later had a PEG tube inserted, which caused a large haemoperitoneum that was not recognised at the time. The concerns were that his deteriorating condition and abdominal pain were not monitored or escalated promptly after the procedure, and that PEG insertion procedures and protocols should be reviewed.

    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 escalate post-PEG patient concerns to a senior doctor for consideration of possible bleeding

    Wider context from the report

    “That once the PEG tube was inserted at Milton Keynes Hospital it seems that the deceased's deteriorating condition was not monitored closely even though he was complaining of abdominal pain soon after the procedure was completed . His concerns were not escalated to a senior doctor for consideration of a possible bleed. The procedures and protocols following PEG insertions should be reviewed. ”

    Source location

    Harry Arthur STOBIE · Prevention of Future Deaths report
    Page 1 · 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 closely monitor deteriorating patients after PEG insertion

    Wider context from the report

    “That once the PEG tube was inserted at Milton Keynes Hospital it seems that the deceased's deteriorating condition was not monitored closely even though he was complaining of abdominal pain soon after the procedure was completed . His concerns were not escalated to a senior doctor for consideration of a possible bleed. The procedures and protocols following PEG insertions should be reviewed. ”

    Source location

    Harry Arthur STOBIE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    James David FLETCHER · 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

    James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

    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 staff knowledge about post-operative PEG risks and contraindications

    Wider context from the report

    “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation. ”

    Source location

    James David FLETCHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure peritonitis risk is identifiable after PEG surgery

    Wider context from the report

    “5) Related to 4) above I am concerned that the risk of peritonitis may have been shrouded by the identified risks of sepsis and of aspiration pneumonia and that the risk of peritonitis also needs to be identifiable by those providing care for patients following such surgery. ”

    Source location

    James David FLETCHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to place required PEG warning labels in patient notes

    Wider context from the report

    “4) I am concerned that there is a lack of knowledge amongst medical and nursing staff who may come into contact with and have the responsibility for the care of patients who have undergone PEG surgery about the post-operative risks of such surgery, in particular the risk of peritonitis, of the signs and symptoms which may give rise to a differential diagnosis of peritonitis and of measures which would be or may be contraindicated in the circumstances that complications, including peritonitis develop. This is illustrated in the present case by an apparent lack of awareness that peritonitis may develop and that the use of the PEG tube in the circumstances concerned was contraindicated and by the omission to place a warning label in the Deceased’s notes as provided for by the applicable protocol. The fact that the use of the PEG tube was contraindicated was not identified in the course of the internal serious incident investigation. ”

    Source location

    James David FLETCHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue a staff Red Alert reinforcing vigilance for post-operative peritonitis and guidance on PEG-tube care.

    Verbatim wording from the response

    “4) A lack of knowledge about risks of peritonitis in patients who have undergone PEG surgery - As identified in the Serious Incident (SI) investigation report signed off by the Chief Executive in December of last year a death after PEG tube insertion is rare and occurs in less than 1% of procedures and peritonitis too is a rare complication. That notwithstanding, staff should be alert to the risk of peritonitis in any patient who has undergone abdominal surgery and I have issued a Red Alert to all staff in the light of this serious incident investigation to remind them of: vigilance in the post-operative period and of the need to be alert to the possibility of peritonitis; and guidelines on the care of PEG tubes.”

    Source location

    2019-0146-Response-by-Blackpool-Teaching-Hospitals-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

  3. Manchester South

    AI-generated summary

    Maria Katarina HRYNIW · 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

    Maria Katarina HRYNIW, who was PEG fed following a stroke and had very limited mobility, developed bronchopneumonia and died at The Lakes Care centre on 14 April 2018. Concerns included the lack of assessment of the suitability and volume of continued PEG feeding near the end of life, continued administration despite reported difficulty coping with the prescribed volume, and unclear responsibilities between the SALT team and care home regarding assessment and decision-making.

    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 assess the suitability and volume of continued PEG feeding in the community

    Wider context from the report

    “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding. ”

    Source location

    Maria Katarina HRYNIW · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.

    Verbatim wording from the response

    “We look at how people’s end of life needs are met under Assessment Framework key question “Is the service Responsive?” The framework has ‘Key Lines of Enquiry’ (KLOEs) for inspectors to follow when answering the key questions. One of the KLOEs for ‘Responsive’ asks: How are people supported at the end of their life to have a comfortable, dignified and pain-free death? Inspectors explore how people, and their family, friends and other carers are involved in planning, managing and making decisions about their end of life care, and how people’s pain and other symptoms are assessed and managed effectively, including having access to specialised support.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    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

    CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.

    Verbatim wording from the response

    “In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    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

    CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.

    Verbatim wording from the response

    “In accordance with CQC’s regulatory remit, as with other regulators, we highlight breaches of the regulations to a Provider and where appropriate ask them what they are going to do to make improvements. We do not tell them what they should do. That is for the Provider and/or Registered Manager (‘registered person’) to decide. CQC does not publish detailed standards and expectations about specific conditions and meeting related needs. To do so would duplicate the work of more appropriate expert sources (for example NICE and SCIE) and impossible to keep safely up to date. It would also make our assessment framework far too long and detailed. We expect registered persons to keep up to date with, take on board and implement good practice standards provided by relevant authoritative organisations.”

    Source location

    2018-0398-Response-by-CQC
    Page 2 · response
    Published 20 December 2018

    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 Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.

    Verbatim wording from the response

    “You will appreciate that I am not in a position to comment on the quality of end of life care provided by the nursing home and others to Ms Hryniw. I expect the Care Quality Commission to respond to you as regulator of health and adult social care in England on its consideration of the matters of concern raised with regard to the provision of services in this case.”

    Source location

    2018-0398-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 20 December 2018

    Open published response

  4. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · 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

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    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 follow written guidance for post-operative abdominal pain after PEG insertion

    Wider context from the report

    “6. The post-operative management of Mr Teesdale did not follow the written guidance for the management of abdominal pain after PEG insertion. This resulted in a delay in seeking appropriate advice, timely intervention and optimal treatment of this complication. ”

    Source location

    Dennis Allen Teesdale · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Rewrite post-PEG care guidance and provide it to all relevant clinicians, including warning-sticker requirements.

    Verbatim wording from the response

    “The guideline on care of patients following a PEG insertion has been re-written and all clinicians involved in PEG placement and the care of patients following PEG placement have received and noted the updated guideline. The guidance includes the requirement for warning stickers to be placed on the patient’s notes and drug chart to alert staff.”

    Source location

    Dennis-Teesdale-Response-1
    Page 4 · response
    Published 28 July 2017

    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

    Monitor the trust’s prospective PEG audit through routine engagement, including adherence to policy and timely escalation of deterioration.

    Verbatim wording from the response

    “Although the trust carried out two PEG insertions since the request, only one of these took place after they introduced the new PEG Pathway on 5 June 2017. The trust confirmed the PEG Pathway was followed for this patient. We will continue to monitor the trust’s prospective PEG audit, which will capture this information, as part of our ongoing engagement with the trust.”

    Source location

    2017-0202-Response-by-Care-Quality-Commission
    Page 5 · response
    Published 28 July 2017

    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

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 2017

    Open published response

  5. Manchester West

    AI-generated summary

    Thomas Nicholls · 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

    Thomas Nicholls died in hospital on 14 April 2015 after recurrent vomiting, aspiration pneumonia and deterioration following PEG feeding, in the context of prior strokes and other illness. The substantive concerns included inadequate staff training in the mobility, handling and care of residents receiving PEG feeds, an unreported vomiting incident, inadequate recording of incidents, and malfunctioning bed equipment.

    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 care-staff training and competence in PEG feeding, including resident mobility, handling and feed controls

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”

    Source location

    Thomas Nicholls · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record and escalate incidents involving PEG feeding

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”

    Source location

    Thomas Nicholls · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of the bed remote control needed to adjust the bed position during PEG feeding

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”

    Source location

    Thomas Nicholls · Prevention of Future Deaths report
    Page 2 · 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