Enteral (GB) UK

Private and voluntary organisations · Company

Pin Request correction

First report 19 Apr 2021•Latest report 19 Apr 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Enteral (GB) UK linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Stephen James Oakes · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen James Oakes, aged 59, died in hospital on 23 December 2017 after a carefeed 14F nasogastric tube inadequately drained stomach contents, allowing vomit to pass the tube and leading to aspiration pneumonia in the context of metastatic bronchial carcinoma and small bowel obstruction. The principal concerns included inadequate product description and staff training, insufficient hospital evaluation of the tube, failure to recognise inadequate drainage or consider alternatives, and possible wider product-labelling problems.

    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. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to align product promotion with safety information about feeding and drainage suitability

    Wider context from the report

    “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see attached link to the Nursing times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient product description of the tube bore restriction

    Wider context from the report

    “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes

    Wider context from the report

    “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14F feeding and drainage tube. Feedback was generally difficult to obtain. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of compulsory root cause analysis training for clinicians

    Wider context from the report

    “(5) There is no compulsory training of clinicians required to undertake root cause analysis. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to train sales marketing staff to recognise and communicate the tube bore restriction

    Wider context from the report

    “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to respond appropriately when NG tubes are not adequately draining

    Wider context from the report

    “(4) Nursing staff did not consider alternative action when the NG tubes were not adequately draining. There was no general recognition of the need to aspirate the tube. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Wider product labelling failure to communicate the connector-related bore restriction

    Wider context from the report

    “(7) This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasogastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also need to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes. ”
    Open source report

  2. Stoke-on-Trent and North Staffordshire

    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. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of compulsory root cause analysis training for clinicians

    Wider context from the report

    “(5) There is no compulsory training of clinicians required to undertake root cause analysis. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Continued promotion of the product as suitable for feeding and drainage despite safety information

    Wider context from the report

    “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see attached link to the Nursing Times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Wider product labelling problem regarding the tube's restricted bore

    Wider context from the report

    “(7) This was a joint inquest into the deaths of two patients who died in quick succession as a result of the Enteral 14F nasogastric tubes being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to train sales marketing staff to recognise and communicate the tube's restricted bore

    Wider context from the report

    “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient product description of the tube's restricted bore

    Wider context from the report

    “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Enteral (GB) UK; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider alternative action when nasogastric tubes do not adequately drain

    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. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026