Misplaced nasogastric tubes in infants
Oxford University Hospitals NHS Foundation Trust received 2 coroners' reports about this hazard between 15 Dec 2020 and 9 Jan 2025.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“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”
Original on judiciary.uk ↗ Oxford University Hospitals NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“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.”
Stated timescale: end of 2019 and beginning of 2020
- 4 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“At the time of [the deceased]'s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance”
Original on judiciary.uk ↗ Oxford University Hospitals NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Oxford University Hospitals NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2025David Tighe4 years 1 month after Don Fernandes · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern the lack or inadequacy of specific nasogastric tube policies within the Trust.
Don Fernandes · 15 Dec 2020
“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”
Original on judiciary.uk ↗ David Tighe · 9 Jan 2025
“At the time of [the deceased]'s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance”
Original on judiciary.uk ↗
Stated action · timescale: end of 2019 and beginning of 2020
“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.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Oxford University Hospitals NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2025 | 0.70 | 0.11 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.