Ellen Taylor

(1) Ms Taylor underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.  On 25th June 2025 she was admitted to hospital having suffered a stroke and was deemed to require a nasogastric tube.  The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially.  (2) I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.  The Northumbria Healthcare NHS Foundation Trust identified areas of learning as a result of the circumstances of Ms Taylor’s death. The key finding from the After Action Review was that the previous gastric surgery was not recognised at the time of the nasogastric tube insertion. Previous surgery was not a routine consideration and not included within the nasogastric tube guideline. Local guidelines have now changed and consultation with on-call surgical team for guidance about insertion of the tube in these circumstances is now included in the process. Training has taken place and a clinical safety message circulated to increase awareness.  Whilst the local NHS Trust have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken.