Amanda Coulthard
18 Jan 2017 · Coroner David Roberts · Cumbria
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. misplaced nasogastric tubes
“Staff not being aware of the policy”
2. misplaced nasogastric tubes
“Staff not reading the policy”
3. misplaced nasogastric tubes
“Staff not applying the policy”
4. misplaced nasogastric tubes
“Staff not following good practice”
5. misplaced nasogastric tubes
“The Trust not ensuring compliance nor rolling out training to all who needed it”
6. misplaced nasogastric tubes
“Lack of checks and audits to establish competence and adherence to policy”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
This report
“not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Closely relatedConfidence 0.90 · high
This report
“Staff not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Later report
“(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.”
Responses
2017-0024-Response.pdf ↗· Department of Health and Social Care
Stated action · 21 April 2017
“Boards were asked to assess and address compliance issues by 21 April 2017”
2017-0025-Response-by-North-Cumbria-University-Hospitals-Trust.pdf ↗· North Cumbria University NHS Trust: NHS England