PFD report

Brian Marks · Prevention of Future Deaths report

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Issued 29 Jan 2015•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Lack of reliable visual differentiation between PEJ and PEG tubes
    Part of recurring concern: Failure to ensure safety-critical medical equipment is reliably visually identifiable
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Further colour coding may not reliably prevent tube confusion and could introduce additional hazards, including misconnections and risks for colour-blind users.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of reliable visual differentiation between PEJ and PEG tubes

Wider context from the report

“The appearance of the PEJ tube and the PEG tube are very similar and could be easily confused the one with the other. In discussion with the witnesses, including the lead dietician, it was agreed that a simple colour coding system could be implemented so that even when in situ, the tubes would be immediately able to be differentiated. ”

Is this part of a recurring concern?

Yes — Failure to ensure safety-critical medical equipment is reliably visually identifiable.

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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

Further colour coding may not reliably prevent tube confusion and could introduce additional hazards, including misconnections and risks for colour-blind users.

Verbatim wording from the response

“Both organisations agree that feeding tubes look very similar and can therefore be confused with one another, potentially putting the patient at risk. However, the solution might not be as straightforward as it first appears.”

Source location

2015-0025-Response-by-Department-of-Health
Page 1 · response
Published 29 January 2015

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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

Manufacturers cannot be compelled to change device designs unless changes form part of internationally required standards.

Verbatim wording from the response

“Your suggestion of introducing a colour coding scheme has already been considered. Some experts in the field believe a suitable scheme could be helpful, although influencing manufacturers to change design to ensure easier visual distinction of their product is not always straightforward. Manufacturers cannot be compelled to make such changes where these are not part of internationally required design standards.”

Source location

2015-0025-Response-by-Department-of-Health
Page 2 · response
Published 29 January 2015

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

Data last updated 7 September 2026