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  • Prevention of Future Deaths report – Van Tuyen (22 February 2022)

    Mark Hughes
    • UK
    • Reports and articles
    • Pre-existing
    • Public domain
    • No
    • Jonathan Stevens
    • 22/02/22
    • Health and care staff, Patient safety leads


    Van Thai Tuyen was admitted to the Royal London Hospital on 1 August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due to 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.


    In his report, the Coroner lists the following matters of concern:

    • Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.
    • 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.
    • The court heard that Barts NHS Trust had at least seven incidents relating to misplaced nasogastric tube since 2012.
    • The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country.
    • The court heard that there is no unified approach to address the ongoing issue of avoidable deaths caused by using misplaced nasogastric tubes.

    This report was sent to the Secretary of State for Health and Social Care, NHS England and Barts Health NHS Trust.

    Misplaced nasogastric tubes

    The life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients is a known patient safety issue. This was identified as a serious patient safety concern in the UK by the National Patient Safety Agency in 2005, by a formal Patient Safety Alert in 2011 and a further Patient Safety Alert in 2016. The Healthcare Safety Investigation Branch issued a report on the placement of nasogastric tubes in December 2020, making a number of safety recommendations in relation to this for NHS England, NHS Supply Chain, Health Education England and the British Society of Gastrointestinal and Abdominal Radiologists.

    Frequency of this ‘Never Event’

    This patient safety incident is formally classified by NHS England as a ‘Never Event’. This is a type of serious incident that is viewed as wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

    NHS England routinely publishes data on the occurrence of Never Events. These figures highlight the annual frequency of the Never Event ‘Misplaced naso- or orogastric tubes and feed administered’ in England:

    • 2020/21 - 34*
    • 2019/20 - 25
    • 2018/19 - 29*
    • 2017/18 - 22
    • 2016/17 - 26

    *When accessed on the 10 March 2022 these figures were marked as provisional rather than final data.

    Related reading

    Prevention of Future Deaths report – Van Tuyen (22 February 2022) https://www.judiciary.uk/publications/van-tuyen-prevention-of-future-deaths-report/
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    Thank you for posting this.

    Coroners' prevention of future deaths reports are important, and the actions resulting from them are vital for patient safety. I look through these reports when preparing clinical education sessions, and have included this link in my teaching resources: https://www.judiciary.uk/subject/prevention-of-future-deaths/ 

    Unfortunately, I believe there is an inconsistency in when Coroners make these reports. For example, in the case of the death of Oliver McGowan, where no such report was made. This is a case study I use in my medicines and prescribing teaching work.

    I've also come across a press reports of a trust putting pressure on a Coroner not to make a prevention of future deaths report. 

    I'm interested in people's views on this. Am I right in thinking that there is an inconsistency in how Coroners use their powers to make prevention of future deaths reports? Are there any other reported examples of trust's trying to put pressure on Coroners?

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    Edited by Steve Turner
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