Oxford University Hospitals NHS Foundation Trust
NHS / Health Body
Disputed
The Trust outlines actions taken following the RCA report, including policy changes and audits. They do not accept the recommendation that the nurse should have sought advice from a senior clinician, and dispute that there was a change in normal policy or uncertainty regarding Don Maximus' care. (AI summary)
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Dear Mr Slater
Regulation 28 Report/Prevention of Future Deaths Inquest into the Death of Don Maximus Del Rocco FERNANDES
Thank you for your letter dated 15 January 2021 with the enclosed Prevention of Future Death Report. I am sorry that you have had cause to write to the Trust in this manner. We have reviewed the points raised in your letter and set out below our response:
1. With reference to the RCA Report at appendix 1: Action Plan, there are a number of recommendations concerning the policy for the insertion and use of NG tubes in infants and a recommendation that the nurse involved be reassessed for NGT competence. It appears that the action points were due for completion at the end of 2019 and beginning of 2020. In particular, I have seen the more user friendly policy and the ‘at a glance’ appendix that now forms part of the policy.
I enquire however if there is an audit of similar incidents involving misplaced tubes in children and whether there have been any subsequent incidents resulting in harm. If there are, I enquire what if any further measures have been introduced?
We have reviewed this point within the Trust. As you will be aware, it is recognised that there is always a risk of an NG tube being misplaced and consequently the checks, as identified in the Trust policy (a copy of which I note you have already seen), are in place to identify a misplaced NG tube before usage. The current national guidance sets out the following ‘Never Event’ definition in relation to the use of NG tubes: ‘Misplacement of a naso- or oro-gastric tube in the pleura or respiratory tract that is not detected before starting a feed, flush or medication The John Radcliffe Headley Way Headington Oxford OX3 9DU
administration. As a consequence The Trust takes such events very seriously any such incident would be identified and investigated, in line with the national Never Event policy, as a matter of routine. I can confirm that no subsequent Never Events or incidents have been identified since this event was reported. I confirm an audit was carried out by the PICC Matron of PICC records for 71 PICC in-patients that showed between 1/11/2020 and 14/11/2020 all NG tubes in situ were aspirated in accordance with the protocol and were compliant. Please find audit attached for your information.
2. There was a further issue concerning Don Maximus’ case. It was noted from Dr Turnham’s statement and oral evidence that the correct position of an NGT in PICU is normally confirmed by aspirating the gastric contents and confirming it is acidic or by performing an x-ray. Measuring the pH of stomach contents is problematic if the child is on antacid medication as it may not test as acidic. I note that Don Maximus required multiple x-rays to confirm placement of the NGT and in order to reduce the need for extra exposure on 20 August 2019 (PICU Consultant) documented that if there was no suspicion of migration or misplacement of the NGT (coughing, choking or vomiting) then it was not necessary to perform an x-ray of the NGT position. This would avoid excess radiation from repeated x- rays. The above would not apply however if the tube had been re-sited or was suspected to have migrated.
In this case an x-ray would be needed to confirm placement. It appears that the nurse in question was concerned about the number of x-rays and was made aware about the change to policy for Don Maximus but it appears that she misunderstood it and did not believe an x-ray was required in this case.
There are two points that arise, firstly, there is the dilemma in terms of the need to correctly confirm the NGT position but also the need to avoid excess radiation. I enquire if there is any other method of reliably confirming the place of the NGT? I assume not as otherwise it would be routine. I understood from information provided at inquest that there are no cameras small enough that can be used to confirm the position.
The second point is the fact that the change to normal policy in Don Maximus case, whilst understandable and perhaps necessary, introduced an element of uncertainty particularly with regard to a nurse caring for Don Maximus for the first time as was the case here. I enquire if there are any additional measures to reduce the prospect of a similar incident occurring in future.
Addressing the points raised above in turn:
a. For all patients (whether children or adults), the gold standard for confirming placement of an NG tube is an x-ray. This is because other tests (such as aspiration of the tube) may produce inaccurate results. Accurate confirmation can only be obtained by way of an x-ray. All clinical staff are acutely aware of the impaction that too many x-rays can have on an individual patient. It is a difficult balancing exercise to avoid excessive radiation, but the only truly reliable method of confirming NG tube placement is from an X-ray.
b. It is not correct to say that there was a change in normal policy when caring for Don Maximus. In accordance with the Trust policy regarding patients who frequently dislodge their NG tube, the nurse caring for this patient had been advised in the morning handover and separately when caring for Don Maximus that an x-ray should be performed if the NG tube had been re-sited (as it was on this occasion) or displaced. This is not specific to Don Maximus – patients on the Paediatric Critical Care Unit will often be ventilated, continuously fed or on acid reducing medication and would therefore be treated in the same way.
c. I do not accept that this created an uncertainty. The role of the handover (as happened on this occasion) is to identify an individual child’s specific care needs. This system was in place in respect of Don Maximus’ care. I can confirm that the specific actions identified from the RCA Action Plan were completed and I am therefore satisfied that all
information was provided to the nurse and that there are no additional measures that should be taken.
I understand that the PFD report that you have sent to the Trust will be published – I should be grateful if this response could be published alongside your report so that a complete picture is publicly available.
I trust this response provides you with sufficient reassurance that all action necessary arising from Don Maximus’ death has been taken.
I would like to offer both my and the Trust’s condolences to Don Maximus’ parents for their loss.
Regulation 28 Report/Prevention of Future Deaths Inquest into the Death of Don Maximus Del Rocco FERNANDES
Thank you for your letter dated 15 January 2021 with the enclosed Prevention of Future Death Report. I am sorry that you have had cause to write to the Trust in this manner. We have reviewed the points raised in your letter and set out below our response:
1. With reference to the RCA Report at appendix 1: Action Plan, there are a number of recommendations concerning the policy for the insertion and use of NG tubes in infants and a recommendation that the nurse involved be reassessed for NGT competence. It appears that the action points were due for completion at the end of 2019 and beginning of 2020. In particular, I have seen the more user friendly policy and the ‘at a glance’ appendix that now forms part of the policy.
I enquire however if there is an audit of similar incidents involving misplaced tubes in children and whether there have been any subsequent incidents resulting in harm. If there are, I enquire what if any further measures have been introduced?
We have reviewed this point within the Trust. As you will be aware, it is recognised that there is always a risk of an NG tube being misplaced and consequently the checks, as identified in the Trust policy (a copy of which I note you have already seen), are in place to identify a misplaced NG tube before usage. The current national guidance sets out the following ‘Never Event’ definition in relation to the use of NG tubes: ‘Misplacement of a naso- or oro-gastric tube in the pleura or respiratory tract that is not detected before starting a feed, flush or medication The John Radcliffe Headley Way Headington Oxford OX3 9DU
administration. As a consequence The Trust takes such events very seriously any such incident would be identified and investigated, in line with the national Never Event policy, as a matter of routine. I can confirm that no subsequent Never Events or incidents have been identified since this event was reported. I confirm an audit was carried out by the PICC Matron of PICC records for 71 PICC in-patients that showed between 1/11/2020 and 14/11/2020 all NG tubes in situ were aspirated in accordance with the protocol and were compliant. Please find audit attached for your information.
2. There was a further issue concerning Don Maximus’ case. It was noted from Dr Turnham’s statement and oral evidence that the correct position of an NGT in PICU is normally confirmed by aspirating the gastric contents and confirming it is acidic or by performing an x-ray. Measuring the pH of stomach contents is problematic if the child is on antacid medication as it may not test as acidic. I note that Don Maximus required multiple x-rays to confirm placement of the NGT and in order to reduce the need for extra exposure on 20 August 2019 (PICU Consultant) documented that if there was no suspicion of migration or misplacement of the NGT (coughing, choking or vomiting) then it was not necessary to perform an x-ray of the NGT position. This would avoid excess radiation from repeated x- rays. The above would not apply however if the tube had been re-sited or was suspected to have migrated.
In this case an x-ray would be needed to confirm placement. It appears that the nurse in question was concerned about the number of x-rays and was made aware about the change to policy for Don Maximus but it appears that she misunderstood it and did not believe an x-ray was required in this case.
There are two points that arise, firstly, there is the dilemma in terms of the need to correctly confirm the NGT position but also the need to avoid excess radiation. I enquire if there is any other method of reliably confirming the place of the NGT? I assume not as otherwise it would be routine. I understood from information provided at inquest that there are no cameras small enough that can be used to confirm the position.
The second point is the fact that the change to normal policy in Don Maximus case, whilst understandable and perhaps necessary, introduced an element of uncertainty particularly with regard to a nurse caring for Don Maximus for the first time as was the case here. I enquire if there are any additional measures to reduce the prospect of a similar incident occurring in future.
Addressing the points raised above in turn:
a. For all patients (whether children or adults), the gold standard for confirming placement of an NG tube is an x-ray. This is because other tests (such as aspiration of the tube) may produce inaccurate results. Accurate confirmation can only be obtained by way of an x-ray. All clinical staff are acutely aware of the impaction that too many x-rays can have on an individual patient. It is a difficult balancing exercise to avoid excessive radiation, but the only truly reliable method of confirming NG tube placement is from an X-ray.
b. It is not correct to say that there was a change in normal policy when caring for Don Maximus. In accordance with the Trust policy regarding patients who frequently dislodge their NG tube, the nurse caring for this patient had been advised in the morning handover and separately when caring for Don Maximus that an x-ray should be performed if the NG tube had been re-sited (as it was on this occasion) or displaced. This is not specific to Don Maximus – patients on the Paediatric Critical Care Unit will often be ventilated, continuously fed or on acid reducing medication and would therefore be treated in the same way.
c. I do not accept that this created an uncertainty. The role of the handover (as happened on this occasion) is to identify an individual child’s specific care needs. This system was in place in respect of Don Maximus’ care. I can confirm that the specific actions identified from the RCA Action Plan were completed and I am therefore satisfied that all
information was provided to the nurse and that there are no additional measures that should be taken.
I understand that the PFD report that you have sent to the Trust will be published – I should be grateful if this response could be published alongside your report so that a complete picture is publicly available.
I trust this response provides you with sufficient reassurance that all action necessary arising from Don Maximus’ death has been taken.
I would like to offer both my and the Trust’s condolences to Don Maximus’ parents for their loss.