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

Summary

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.

Content

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

• Healthcare Safety Investigation Branch, Placement of nasogastric tubes, December 2020
• Tracy Earley, Improving safety with nasogastric tubes: a whole-system approach, 25 November 2019