University Hospitals Birmingham NHS Foundation Trust

3. Mrs B complains that in December 2023, staff at the Trust used too much water to flush her husband, Mr B’s nasogastric (NG) feeding tube.

4. Mrs B says this caused her husband to vomit and he aspirated (choked) on his vomit. She says this lead directly to his death the next day. She explains that she thinks constantly about the unfair way in which her husband died, and this badly affects her sleep and health.

5. Mrs B is seeking service improvements and would like the Trust to acknowledge what went wrong and apologise.

6. In November Mr B had been unwell and short of breath. His GP had prescribed two courses of antibiotics, which did not work well to treat his illness. He was still short of breath, and the Trust admitted him to treat an exacerbation of chronic obstructive pulmonary disease (COPD). This is a progressive lung disease which makes it difficult to breathe.

7. A few days after he went to hospital, Mr B he vomited and developed a cough. Doctors started antibiotics to treat a suspected pneumonia (chest infection) and intravenous (directly into the vein) fluids. The speech and language therapy (SALT) team were concerned that he had a risk of choking on food. They recommended nurses feed Mr B via an NG tube, through which a pump feeds liquid food directly to the stomach.

8. By December, Mr B’s condition had improved. SALT advised nurses to wean Mr B off NG tube feeding and onto pureed foods. Mr B ate his first evening meal for several weeks and a nurse set up an NG feed. Shortly after the feed started, Mr B vomited again and his oxygen levels dropped sharply. The next day he sadly died. Doctors recorded Mr B’s cause of death as aspiration of vomit with COPD, Parkinson’s disease, and community acquired pneumonia.

12. Mrs B told us her husband had enjoyed his first evening meal in some weeks before a nurse started setting up the planned NG feed. Her husband’s friend was visiting during this time and noticed the nurse used seven syringes of water to flush the tube before starting the evening NG tube feed. Mrs B recalls staff normally used two syringes. She thinks her husband’s stomach was not used to this volume of food and liquid, and this made him vomit. She told us a doctor she saw after the incident said the nurse gave her husband too much water. We do not know what size or sizes of syringe Mrs B and the friend saw the nurse use.

13. The Trust said it needed several syringes of water to give Mr B the amount of water prescribed as well as his medication. It also said the nurse used additional syringes to unblock the tube. It said between 200 and 400ml of water was given to Mr B in total.

14. Nurses need to flush NG feeding tubes with water to clear any blockages before and after use. Records show the Trust’s dietician initially recommended 60ml of water to flush the tube before and after each feed and an additional 60ml to give Mr B his medication. A week before the Trust decided to wean Mr B off the NG feed, these amounts were both increased to 100ml. This recommendation remained in place when the dietician planned for weaning, with the amount of feed reducing over three days and then stopping.

15. The NICE guideline does not detail the process to flush a tube. It says nurses should follow local criteria for processes such as checking tube location. The Trust’s guideline does not say how much water nurse should use to flush NG tubes or give medication. However, it does say nurses should always use a 60ml syringe to flush NG tubes. This relates to the type of equipment used rather than the volume of water.

16. Our adviser explained that different patients can tolerate different amounts and rates of feed. They were unaware of a specific limit to the amount of water which nurses should use to flush a tube. Typically, 30 to 60ml is appropriate for a flush or up to 100ml for hydration. Nurses can give larger flushes, of up to 200ml, slowly in separate syringes to prevent discomfort. Where possible, nurses should time feed and flushes away from mealtimes, as this can help to increase a patient’s appetite. They noted Mr B had been tolerating the increased amount for a week before he vomited and therefore there was no indication vomiting was a particular risk. There is no evidence Mr B could not tolerate a larger amount of up to 400ml.

17. Both sets of guidelines give discretion to the dietician to plan the amount of water. Additionally, Mr B had been tolerating the amount set out in the plan for a week before he vomited. We saw no indication there was anything wrong with the dietician’s recommendation to use 100ml to flush the NG tube and a further 100ml to give Mr B his medication.

18. We also considered whether the nurse followed the plan set out by the dietician. The Trust’s electronic records include a fluid chart for nurses to record how much fluid a patient has received and how. The nurse did not complete this chart on the day we are considering.

19. The nurse’s notes explain they had given Mr B some medication with his yoghurt at about 6.50pm, which he tolerated well. They flushed his NG tube, however they did not state the amount of water they used in the notes. About five minutes later Mr B vomited and his oxygen levels dropped sharply, causing the nurse to summon a doctor for an urgent review.

20. The nurse gave a statement for the complaint investigation, which gave some more information about the water flush. They said the tube had become blocked on this occasion, so they had used additional syringes to clear it, starting with a 10ml syringe. They said they typically use 20ml and 60ml syringes to clear a blockage. They also said the doctors had asked the nurses to give Mr B 200ml of water for hydration. They added this had not been properly documented, but it had been going on for several days. The records do show amounts between 200 and 300ml for a few days prior. The nurse said they usually used four 60ml syringes to give this water, which totals 240ml, not 200ml.

21. Our adviser explained there is no fixed figure for ‘too much’ water, as different patients react differently. Appetite and discomfort are considerations for dieticians and nurses. Nurses manage these by the timing of feeds and by running the feed or fluid more slowly. It appears the amount of water nurse gave Mr B had been increasing and he had been tolerating this for several days. On this day he started eating again, but the dietician recommended less feed through the NG tube to compensate for his meals.

22. There are some limitations with the evidence, so we do not know exactly how much water the nurses gave Mr B through the flush, other than it was in line with or slightly more than he had received in previous days. Mrs B told us a doctor said the nurse gave her husband too much water. The doctor’s comments are not in Mr B’s record or the Trust’s response. We do not know what prompted the doctor’s opinion or whether there was a misunderstanding. Taking all of this into account, we do not think this amounts to an indication the nurse flushed Mr B’s NG tube with too much water.

23. Mrs B is naturally very distressed by what happened. Her understanding, from what the doctor and her husband’s friend told her, is that the water introduced to her husband’s stomach directly caused him to vomit. While we have not reached a conclusion about whether or not it did, we hope she is reassured that we did not see an indication this is because the Trust used too much water to flush the NG tube. Our consideration is not intended to detract from what we recognise was a very difficult and sad experience for Mrs B.

1. We have carefully considered Mrs B’s complaint about the Trust. We have seen no indication the Trust used or should have known it was using too much water to flush Mr B’s feeding tube. This means we have decided not to take further action on Mrs B’s complaint.

2. We are sorry to learn of Mr B’s death at a time Mrs B hoped he would soon be home. Mrs B told us concerns about her husband’s care made her bereavement more difficult. We hope she finds our consideration helpful in understanding these events.