7 Jun 2017 Dennis Allen Teesdale · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 15 Lack of timely on-site emergency laboratory testing and results View source Failure to recognise severe clinical deterioration on consultant ward rounds View source Poor multidisciplinary communication for consistent systematic patient management View source Unavailability of specialist facilities or clinicians for peri-operative PEG insertion View source Lack of assured competence for peri-operative PEG insertion View source Failure to seek expert advice during daytime working hours View source Lack of out-of-hours radiology and on-site CT diagnostic capacity View source Failure to follow written guidance for PEG insertion View source Failure to follow written guidance for post-operative abdominal pain after PEG insertion View source Lack of on-site specialist clinical support for complications View source Lack of formal PEG insertion training and independent competency assessment View source Inconsistent daytime consultant presence in the High Dependency Unit View source Delays in transferring patients requiring post-operative specialist care View source Lack of assured general surgical competence in out-of-hours cover View source Failure to risk-assess the appropriateness of PEG insertion View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 16
Action
Rewrite post-PEG care guidance and provide it to all relevant clinicians, including warning-sticker requirements.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2017. View source
Action
Rewrite the Enteral Feeding Guideline to clarify absolute and relative PEG contraindications.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2017. View source
Action
Review options for providing CT scanning on site at QVH.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Review intranet policy accessibility and consider governance-based policy dissemination.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2017. View source
Action
Remind staff about timely specialist referrals and transfers through governance meetings and written briefings.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2017. View source
Action
Develop multidisciplinary communication training, including staff ability to challenge decision-makers.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Train staff on PEG risks, postoperative care, human factors and indications for urgent transfer.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Progress the BSUH partnership memorandum and develop robust documentation or an SLA for specialist services.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Localise and deliver QVH-specific human-factors training.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2017. View source
Action
Develop electronic document management to integrate multidisciplinary documentation, enhanced recovery pathways and patient alerts.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2017. View source
Action
Audit prospective PEG practice, including stickers, MDT documentation, consent and checklist use.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2017. View source
Action
Use unified multidisciplinary critical-care documentation and audit its implementation within the enhanced recovery programme.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Use a PEG safety checklist with documented MDT decisions, contraindication checks, stop points and risk assessments.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2017. View source
Action
Review alternative pathways and external oversight for PEG placement, including competency-based training and accreditation.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Monitor, audit and investigate transfers for investigation or referral through clinical governance and Datix processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017. View source
Action
Define critical-care leadership and accountability under the consultant in charge, with consultant-led handover for junior night staff.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2017. View source See 13 more actions
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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.
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× 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely on-site emergency laboratory testing and results
Wider context from the report “12. There are no haematology or biochemistry services at QVH . A courier service is required for emergency laboratory tests . This has the potential to either not request ‘bloods’ and/or a delay in obtaining results .
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise severe clinical deterioration on consultant ward rounds
Wider context from the report “10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward round at or around 0900 on the 19th October 2016, despite considerable evidence present at the time that Mr Teesdale had developed multi-organ failure.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor multidisciplinary communication for consistent systematic patient management
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist facilities or clinicians for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery , thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assured competence for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively .
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek expert advice during daytime working hours
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications. As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’ .
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours radiology and on-site CT diagnostic capacity
Wider context from the report “Similarly, there is no ‘out of hours’ radiology service and there is no CT scanner on site to assist in a diagnosis (which was required as part of the management guidelines prepared by QVH).
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow written guidance for PEG insertion
Wider context from the report “3. Written guidance by the surgeons for insertion of PEG’s was not followed with little reflection as to whether this was an acceptable procedure given Mr Teesdale’s previous extensive surgery at or around the point where the PEG was inserted with concomitant poor gastroscopic trans-illumination.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
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.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site specialist clinical support for complications
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications . As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal PEG insertion training and independent competency assessment
Wider context from the report “5. No formal ‘training’ programme for the insertion of PEG or independent competency based assessment .
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent daytime consultant presence in the High Dependency Unit
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day .
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients requiring post-operative specialist care
Wider context from the report “7. Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the immediate post operative period complicated by the associated logistical difficulties of doing so given his major surgery.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assured general surgical competence in out-of-hours cover
Wider context from the report “9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication.
” 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 Queen Victoria Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to risk-assess the appropriateness of PEG insertion
Wider context from the report “4. No risk assessment was undertaken as to whether a PEG insertion would have been appropriate , given that a non-invasive alternative of a feeding tube for enteral feeding was available.
” 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
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 Rewrite the Enteral Feeding Guideline to clarify absolute and relative PEG contraindications.
Verbatim wording from the response “A number of changes have been made to our process prior to the insertion of PEGs at QVH to minimise the risk of this incident ever being repeated. The requirement for enteral feeding and the decision as to the most appropriate route and any contraindications is now a documented decision at the multidisciplinary team meeting prior to surgery. A PEG safety checklist has been introduced, which includes stop points prior to the insertion, with a final check on contraindications and a stop point if poor gastric distention or poor trans-illumination is achieved. The Enteral Feeding Guideline, which includes the guidance on PEG insertion, has been re-written following this incident, widening and clarifying the absolute and relative contraindications to PEG placement.” Source location Dennis-Teesdale-Response-1
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 options for providing CT scanning on site at QVH.
Verbatim wording from the response “Urgent consideration is being given to options for CT provision at QVH. If it would be helpful we would be happy to update you on progress.” Source location Dennis-Teesdale-Response-1
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 intranet policy accessibility and consider governance-based policy dissemination.
Verbatim wording from the response “G2 — Review the accessibility of the policies and how easy it is to find individual policies on intranet.
Owner: JMT/EP/CP. Date: 1 September 2017. Outcome: Head of risk to undertake review. Consider introduction of policy of the month presentation at local governance meetings. Governance leads to explore. N” Source location Dennis-Teesdale-Response-1
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 Remind staff about timely specialist referrals and transfers through governance meetings and written briefings.
Verbatim wording from the response “In general, specialist opinion and imaging are available through regularly and appropriately used agreements with BSUH. We have reminded all relevant staff of the importance of timely referrals and transfers, through local and hospital-wide multidisciplinary governance meetings and written briefing, with learning from this case.” Source location Dennis-Teesdale-Response-1
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 Develop multidisciplinary communication training, including staff ability to challenge decision-makers.
Verbatim wording from the response “C5 Multidisciplinary communication training, including ability to challenge decision maker
Owner: EP/JMT
Due: Review 1 Oct 2017
Continuous programme of values, behaviours and communication.
Status: N” Source location Dennis-Teesdale-Response-1
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 Train staff on PEG risks, postoperative care, human factors and indications for urgent transfer.
Verbatim wording from the response “The reluctance to transfer a patient immediately post-surgery meant the recommended investigation for this clinical scenario was not undertaken. It is vitally important that we learn from the sad death of Mr Teesdale, and we are ensuring all relevant staff are aware of the risks and post-operative care of PEGs and the indications for transfer. In recognition of the potential reluctance to transfer, this will be included in ‘human factors’ training for staff at QVH. Transfers from QVH for investigation and referral are, and will continue to be, monitored, audited and shared through the clinical governance processes of the Trust. Any potential delay in transfers are reported through the Datix system and investigated appropriately.” Source location Dennis-Teesdale-Response-1
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 Progress the BSUH partnership memorandum and develop robust documentation or an SLA for specialist services.
Verbatim wording from the response “We have a particularly close working relationship with BSUH, which includes provision of specialist input for paediatric services, acute medical and care of the elderly. A memorandum of understanding between BSUH and QVH has been approved by the QVH board, and is in the process of being reviewed and approved by the BSUH board. This sets out the nature of the future partnership between QVH and BSUH, working together across burns, plastics, trauma and maxillofacial surgery, mitigating co-dependency for both trusts.” Source location Dennis-Teesdale-Response-1
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 Localise and deliver QVH-specific human-factors training.
Verbatim wording from the response “B6 Engage with Quality Surveillance Group
Owner: SJV/EP/JMT
Due: 3 Aug 2017
Status: N” Source location Dennis-Teesdale-Response-1
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 Develop electronic document management to integrate multidisciplinary documentation, enhanced recovery pathways and patient alerts.
Verbatim wording from the response “The Coroner drew attention to inconsistencies between the ‘snap shot’ medical reviews and the more frequent reviews of the nursing staff. Since Mr Teesdale’s death, we have developed unified multidisciplinary documentation as part of the enhanced recovery programme, and are auditing its use. Multidisciplinary documentation will be further developed as we progress with electronic document management.” Source location Dennis-Teesdale-Response-1
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 Audit prospective PEG practice, including stickers, MDT documentation, consent and checklist use.
Verbatim wording from the response “A12 Ensure prospective PEG audit in place and capturing all necessary information
Owner: BSB/ID
Due: 31 Jul 2017
Audit will capture NPSA stickers, multidisciplinary team documentation, consent, checklist.
Status: Y” Source location Dennis-Teesdale-Response-1
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 Use unified multidisciplinary critical-care documentation and audit its implementation within the enhanced recovery programme.
Verbatim wording from the response “The Coroner drew attention to inconsistencies between the ‘snap shot’ medical reviews and the more frequent reviews of the nursing staff. Since Mr Teesdale’s death, we have developed unified multidisciplinary documentation as part of the enhanced recovery programme, and are auditing its use. Multidisciplinary documentation will be further developed as we progress with electronic document management.” Source location Dennis-Teesdale-Response-1
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 Use a PEG safety checklist with documented MDT decisions, contraindication checks, stop points and risk assessments.
Verbatim wording from the response “A number of changes have been made to our process prior to the insertion of PEGs at QVH to minimise the risk of this incident ever being repeated. The requirement for enteral feeding and the decision as to the most appropriate route and any contraindications is now a documented decision at the multidisciplinary team meeting prior to surgery. A PEG safety checklist has been introduced, which includes stop points prior to the insertion, with a final check on contraindications and a stop point if poor gastric distention or poor trans-illumination is achieved. The Enteral Feeding Guideline, which includes the guidance on PEG insertion, has been re-written following this incident, widening and clarifying the absolute and relative contraindications to PEG placement.” Source location Dennis-Teesdale-Response-1
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 alternative pathways and external oversight for PEG placement, including competency-based training and accreditation.
Verbatim wording from the response “Notwithstanding the view that it is safe for QVH surgeons to continue to place PEGs, the continuation of PEG placement by OMFS surgeons at QVH is currently under review. Alternative pathways are being explored for the provision of PEG placement for enteral feeding for all our patients via gastroenterologists or radiologists at the patients’ referring hospital or the hospital of the referring multidisciplinary team.” Source location Dennis-Teesdale-Response-1
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, audit and investigate transfers for investigation or referral through clinical governance and Datix processes.
Verbatim wording from the response “Admission policies and consultant pre-assessment minimise the risk of needing to transfer patients. We closely monitor our transfers out for investigation and referral. Our current rate is 0.2% across adults and paediatrics. This rate reflects the networked care we provide. Guidelines are in place to support patient transfers when needed. Staff are mindful of the need to seek appropriate referral when needed, and the learning from this case has reiterated the need for appropriate thresholds.” Source location Dennis-Teesdale-Response-1
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 Define critical-care leadership and accountability under the consultant in charge, with consultant-led handover for junior night staff.
Verbatim wording from the response “Leadership of the critical care unit has been better defined with an improved system of handover, and the on-site consultant presence has been extended recently, with consultant led handover for junior night staff.” Source location Dennis-Teesdale-Response-1
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 existing laboratory network and urgent courier arrangements are considered sufficient, with no evidence they reduce blood-test requests or breach processing requirements.
Verbatim wording from the response “Blood pathology services are provided by Princess Royal Hospital, Haywards Heath. There are seven routine transits of blood samples per day during the week, and four at weekends. If urgent blood results are required outside of these routine transits, an urgent courier service is available at any time, day or night, seven days per week. There is no evidence that this network arrangement impacts on the likelihood of requesting bloods. No concerns regarding this long standing arrangement have been raised by NHS England or the Care Quality Commission in their reviews. As part of the SLA with BSUH for blood pathology services, the Trust requires that urgent specimens can be received and processed at the lab ready for testing within one hour of leaving QVH. This is an essential pass/fail requirement.” Source location Dennis-Teesdale-Response-1
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 QVH considers its consultants’ experience and existing PEG practice sufficient to continue PEG placement, although continuation remains under review.
Verbatim wording from the response “There are six consultant OMFS head and neck oncology surgeons at QVH, all of whom are dually qualified in medicine and dentistry. All six consultants have completed Basic Surgical Training, with associated endoscopic exposure, with award of Fellowship or Membership of the Royal College of Surgeons (RCS) in surgery in general, in addition to their specialist qualifications. Their training in the placement of PEGs has been gained whilst training in maxillofacial surgery at QVH. Since the incident, the Medical Director has discussed training, accreditation and best practice with a regional centre specialising in PEG placement, and the Clinical Lead for Head and Neck oncology surgery has attended a PEG placement list with experienced surgeons with a larger volume PEG practice at Maidstone in order to review techniques and ensure practice at QVH is up to date.” Source location Dennis-Teesdale-Response-1
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 QVH disputes that its lack of on-site specialists prevents access to specialist opinion, because agreements with BSUH provide specialist advice and imaging.
Verbatim wording from the response “Queen Victoria Hospital NHS Foundation Trust (“QVH”) is a specialist surgical hospital. We work in close partnership with other provider trusts both providing services on other sites and benefitting from the expertise of clinicians from other provider trusts who work on the Queen Victoria Hospital site.” Source location Dennis-Teesdale-Response-1
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 Difficult PEG placements should be undertaken by radiology or gastroenterology specialists at the referring hospital or multidisciplinary team’s hospital.
Verbatim wording from the response “The pathway for difficult PEG placements is for the patients’ referring hospital or the hospital of the referring multidisciplinary team to place the PEG using radiology or gastroenterology specialists so more complex PEG placements are not performed at QVH.” Source location Dennis-Teesdale-Response-1
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations