Source · Prevention of Future Deaths
Robert Owens
Ref: 2017-0102
Date: 4 Apr 2017
Coroner: Andrew Barkley
Area: South Wales Central
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe health board's guideline for naso-gastric tube insertion and confirmation was outdated, and national guidelines advocating pH testing after insertion were not followed. Additionally, the insertion checklist was not consistently applied, with no clear guidance in place for the ITU setting.
Date
4 Apr 2017
56-day deadline
11 Jul 2017 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The health board's guideline for naso-gastric tube insertion and confirmation was outdated, and national guidelines advocating pH testing after insertion were not followed. Additionally, the insertion checklist was not consistently applied, with no clear guidance in place for the ITU setting.
View full coroner's concerns
During course of the inquest, the evidence revealed matters giving rise t0 concern In my opinion there is a risk that future deaths will occur unless action is taken; In the circumstances it is my statutory to report to you (uL The Cwym Taf University Health Board Guideline Procedure for Naso Gastric fed 27th day the the duty
Insertion and Positional Confirmation 2009 had not been updated and reviewed It was due for review in 2012.
(2) Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and X-raying of a patient after the insertion of tube; these guidelines where never followed. evidence revealed that it is common practice within the Health Board only t0 X-ray and not to follow the National Guidance of PH testing: (3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment:
Insertion and Positional Confirmation 2009 had not been updated and reviewed It was due for review in 2012.
(2) Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and X-raying of a patient after the insertion of tube; these guidelines where never followed. evidence revealed that it is common practice within the Health Board only t0 X-ray and not to follow the National Guidance of PH testing: (3) Contrary to the National Guidance it appears that the check list following insertion of a NG tube was not followed either although this now represents the policy within the Health Board. The evidence revealed that the practice differs depending on the setting (ward or ITU) and no clear guidance is in place for the ITU setting which, it was suggested, was required because of the particularities of practice in that environment:
Report sections
Investigation and inquest
On the 20th December 2016 commenced an investigation into the death of Robert John Owens_ The investigation concluded at the end of the inquest on the 29"h March 2017 The conclusion of the inquest was that of a narrative conclusion. "Robert John Owens died as a result of septic shock when through a misplaced naso gastric tube on the intensive care unit at the Prince Charles Hospital. Merthyr Tydfil in circumstances in which National Guidance of the placement was not followed"
Circumstances of the death
Mr Owens was a 68 year old gentlemen admitted to the Prince Charles Hospital on the November with back pain. Whilst in hospital he developed an acute kidney and respiratory failure and had to be admitted to the Intensive Care Unit on the iniury December 2016. He was fed through a Naso Gastric Tube: That became dislodged on the 13"h December and was replaced on the 14th. An X-ray was taken to ensure the correct placement of the tube which was, it transpired, misinterpreted. Feeding commenced and he became unwell later that and into the early hours of the following morning: A subsequent x-ray undertaken t0 check the position of a new Central Venous Line demonstrated a "whiteout" of the left lung field and the misplacement of the NG tube: Despite efforts to revive him his condition deteriorated and he passed away on 16"h December 2016.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.
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Report details
- Reference
- 2017-0102
- Date of report
- 4 April 2017
- Coroner
- Andrew Barkley
- Coroner area
- South Wales Central
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 11 Jul 2017 (estimated from the Judiciary.uk publication date).
Sent to
- CWM Taf University Health Board