PFD report

Colin Beaumont · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 19 Dec 2019•Warwickshire

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.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to correctly place nasogastric tubes
    Part of recurring concern: Unsafe management of Ryles and nasogastric tubes
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Amend the nasogastric tube insertion policy to require alternative-feeding review and renewed risk discussions after repeated failed or misplaced insertions.

    Stated by South Warwickshire University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2020.
  2. Action

    Explore sourcing an e-learning nasogastric tube refresher module with the learning and development team.

    Stated by South Warwickshire University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 January 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Staff training was not a factor in the events because the staff involved were competent and followed current policy.

    Stated by South Warwickshire University NHS Foundation TrustDisputes 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

Failure to correctly place nasogastric tubes

Wider context from the report

“(1) the fact that a Naso Gastric tube was misplaced twice in the same patient leading to a pneumothorax which directly contributed to death ”

Is this part of a recurring concern?

Yes — Unsafe management of Ryles and nasogastric tubes.

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

Amend the nasogastric tube insertion policy to require alternative-feeding review and renewed risk discussions after repeated failed or misplaced insertions.

Verbatim wording from the response

“Whether the Trust policy for Nasogastric Tube Insertion was appropriate and whether, as a result of this case, it should be amended in any way.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 1 · response
Published 6 January 2020

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

Explore sourcing an e-learning nasogastric tube refresher module with the learning and development team.

Verbatim wording from the response

“Whether staff training in Nasogastric Insertion is appropriate.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 1 · response
Published 6 January 2020

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

Staff training was not a factor in the events because the staff involved were competent and followed current policy.

Verbatim wording from the response

“Whether staff training in Nasogastric Insertion is appropriate.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 1 · response
Published 6 January 2020

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

No further action is proposed regarding staff competency because both practitioners were trained, competent and followed current policy.

Verbatim wording from the response

“Whether staff were suitably trained and competent to undertake the Nasogastric Tube Insertion.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 2 · response
Published 6 January 2020

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 nasogastric tube procedure was clinically appropriate, with pneumothorax recognised as a small inherent risk.

Verbatim wording from the response

“Interventions of this type are not undertaken lightly as there are recognised associated risks including that of pneumothorax, which Mr Beaumont unfortunately experienced. Nasogastric feeding tubes are passed to prevent malnutrition and so help the patient recover from their illness. The inherent mortality risk of malnutrition is balanced against the, often lesser, risks associated with the inserting of a nasogastric tube. In this case Mr Beaumont’s difficulty in swallowing was felt to be more likely a result of his infection from pneumonia rather than his stroke and so any feeding tube was likely to be short term in duration. Ensuring that Mr Beaumont had sufficient nutrition would also be essential in allowing him to fight the infection and recover to his previous level of health.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 2 · response
Published 6 January 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Schedule a Grand Round discussion to share learning with consultants and address clinical-risk balancing, risk communication, and treatment-futility discussions.

    Stated by South Warwickshire University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2020.

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

Schedule a Grand Round discussion to share learning with consultants and address clinical-risk balancing, risk communication, and treatment-futility discussions.

Verbatim wording from the response

“This discussion did bring up a number of medical, ethical and legal considerations and the Group felt that it would be useful for this discussion to be held with a wider group of Trust staff and so we have committed to discussing the above points at a future ‘Grand Round’ clinical meeting. Grand Rounds are a formal meeting at which senior clinicians discuss the clinical case of one or more patients. They are an integral component of medical education and highlight clinical problems in medicine by focusing on current or interesting cases and are also sometimes utilised for dissemination of new research information.”

Source location

2019-0449-Response-from-South-Warwickshire-NHS-Foundation-Trust
Page 2 · response
Published 6 January 2020

Open published response
Back to top

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