Misplaced or removed nasogastric tube
Barts Health NHS Trust received 2 coroners' reports about this hazard between 22 Feb 2022 and 30 Aug 2024.
They came from 2 different coroners in 2 coroner areas. 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 0 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
Original on judiciary.uk ↗ Barts Health NHS Trust responded.Response (PDF) ↗
- 2 years 6 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy.”
Original on judiciary.uk ↗ Repeated from the earlier report:tubemisplaced
Barts Health NHS Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Barts Health NHS 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.
2022 → 2024Terence Clark2 years 6 months after Van Tuyen · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports concern the improper placement or removal of a nasogastric tube leading to preventable harm.
Van Tuyen · 22 Feb 2022
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
Original on judiciary.uk ↗ Terence Clark · 30 Aug 2024
“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Barts Health NHS 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 |
|---|---|---|---|---|
| 2022 → 2024 | 0.65 | 0.11 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Barts Health NHS Trust
- Lack of transport suitability assessment for changing patient conditions2 reports · 2020–2026
- Governance failure in incident identification and poor quality of clinical notes3 reports · 2023–2025
- Over-reliance on NEWS algorithm and inadequate monitoring of deteriorating ED3 reports · 2024–2025
- Lack of strategic governance hindering incident identification2 reports · 2023–2025
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.