VAN THAI TUYEN · Prevention of Future Deaths report

On 31st August 2021 Assistant Coroner Stevens commenced an investigation into the death of VAN THAI TUYEN [age 96].

The investigation concluded at the end of the inquest on 2nd February 2022.

The conclusion of the inquest was that death was a consequence of neglect namely a failure to identify that a nasogastric tube had been misplaced before commencing feeding.

The medical cause of death was:

1 (a) cavitating necrotising pneumonia
(b) misplaced nasogastric tube

2. Cerebrovascular disease, hypertension, diabetes mellitus, Parkinson’s disease

Mr Van Thai Tuyen was admitted to the Royal London Hospital on 1st August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died.

(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.

(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.

(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.

(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country

(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.