Robert John Owens · Prevention of Future Deaths report

On the 20th December 2016 I commenced an investigation into the death of Robert John Owens. The investigation concluded at the end of the inquest on the 29th March 2017. The conclusion of the inquest was that of a narrative conclusion. "Robert John Owens died as a result of septic shock when fed through a misplaced naso gastric tube on the intensive care unit at the Prince Charles Hospital. Merthyr Tydfil in circumstances in which National Guidance of the placement was not followed".

Mr Owens was a 68 year old gentlemen admitted to the Prince Charles Hospital on the 27th November with back pain. Whilst in hospital he developed an acute kidney injury and respiratory failure and had to be admitted to the Intensive Care Unit on the 1st December 2016. He was fed through a Naso Gastric Tube. That became dislodged on the 13th December and was replaced on the 14th. An x-ray was taken to ensure the correct placement of the tube was, it transpired, misinterpreted. Feeding commenced and he became unwell later that day and into the early hours of the following morning. A subsequent x-ray undertaken to check the position of a new Central Venous Line demonstrated a “whiteout” of the left lung field and the misplacement of the NG tube. Despite efforts to revive him his condition deteriorated and he passed away on the 16th December 2016.

(1) The Cwm Taf University Health Board Guideline Procedure for Naso Gastric Insertion and Positional Confirmation 2009 had not been updated and reviewed. It was due for review in 2012.

(2) Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and x-raying of a patient after the insertion of a tube, these guidelines were never followed. The evidence revealed that it is common practice within the Health Board only to x-ray and not to follow the National Guidance of PH testing.

(3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not being followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment.