Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate note keeping of nasogastric tube placement
The earlier warning
Frederick Davidson · 14 Oct 2013 · Martin Flemimg, Surrey
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
What was promised
Stated action 1 · response to Amanda Coulthard (18 Jan 2017) · stated timescale: 21 April 2017
“Boards were asked to assess and address compliance issues by 21 April 2017”
judiciary.uk/wp-content/uploads/2017/02/2017-0024-Response.pdf
Stated action 2 · response to Michael Parke (18 Jan 2017) · stated timescale: 21 April 2017
“Boards were asked to assess and address compliance issues by 21 April 2017”
judiciary.uk/wp-content/uploads/2017/02/2017-0024-Response.pdf
What recurred
- 18 Jan 2017 · Amanda Coulthard · David Roberts · Closely related · confidence 0.90 (high)
- 18 Jan 2017 · Michael Parke · David Roberts
- 22 Feb 2022 · Van Tuyen · Jonathan Stevens · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Michael Parke · 18 Jan 2017
“Common themes in all were: (a) _ Staff not being aware of the policy.”
Later · Van Tuyen · 22 Feb 2022
“The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.”
What happened next
No web check of the stated actions has been published for this chain.