Ellen Taylor
13 Feb 2026 · Coroner Sarah Middleton · Northumberland
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. oesophagus attached to small bowel
“Ms [name redacted] underwent gastric/bariatric surgery in 2009. As a result of this her oesophagus was not attached to her stomach but instead attached to her small bowel.”
2. absence of nasogastric tube guidelines for prior gastric surgery
“I heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery.”
3. wider risk of future deaths
“my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
This report
“heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery”