Warning: include_once(/home/allcatsrgrey/public_html/wp/wp-content/plugins/wp-filebase-pro-less-old/classes/ProLib.php): failed to open stream: No such file or directory in /home/allcatsrgrey/public_html/wp/wp-content/plugins/wp-filebase-pro-less-old/wp-filebase.php on line 57

Warning: include_once(): Failed opening '/home/allcatsrgrey/public_html/wp/wp-content/plugins/wp-filebase-pro-less-old/classes/ProLib.php' for inclusion (include_path='.:/opt/cpanel/ea-php71/root/usr/share/pear') in /home/allcatsrgrey/public_html/wp/wp-content/plugins/wp-filebase-pro-less-old/wp-filebase.php on line 57

WP-Filebase Error: Could not include class file 'ProLib'!

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Date of report: 22 February 2022

Ref: 2022-0058

Deceased name: Van Tuyen

Coroner name: Jonathan Stevens

Coroner Area: Inner North London

Category: Hospital Death (Clinical Procedures and medical management) related deaths

This report is being sent to: Secretary of State for Health and Social Care, Barts Health NHS Trust and NHS England

Matters of concern:

  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.