Recurance · prevention of future deaths reports
Pre-inquest brief
Misplaced nasogastric tube in patients with prior gastric surgery
The earlier warning
Van Tuyen · 22 Feb 2022 · Jonathan Stevens, Inner North London
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 13 Feb 2026 · Ellen Taylor · Sarah Middleton · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Ellen Taylor · 13 Feb 2026
“heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery”
What happened next
No web check of the stated actions has been published for this chain.