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  • Prevention of Future Deaths Reports – Stephen Oakes and Peter Hussey

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Margaret Jones
    • 19/04/21
    • Health and care staff, Patient safety leads

    Summary

    These coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action.

    Content

    The author of both reports, Margaret Jones HM Assistant Coroner, notes the matters of concern are as follows:

    1. The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector.
    2. Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change.
    3. The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube. Feedback was generally difficult to obtain.
    4. Nursing staff did not consider alternative action when the NG tubes were not adequately draining. There was no general recognition of the need to aspirate the tube.
    5. There is no compulsory training of clinicians required to undertake root cause analysis.
    6. Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see link to the Nursing times.
    7. This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasosgastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.

    Read the report relating to Peter Hussey

    Read the report relating to Stephen Oakes

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