Reginald Bourn
8 Aug 2023 · Coroner Caroline Topping · Surrey
The coroner's concerns
1. misplacement of nasogastric tube into lung
“The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus”
2. lack of insertion and placement instructions for decompression tubes
“The feeding tubes have instructions both as to how to insert them and as to how to ensure that they are correctly placed. The decompression tubes have neither”
3. absence of national guidance for decompression tubes
“The expert evidence was that there is national guidance in relation to the placement of nasogastric feeding tubes but not nasogastric decompression tubes. However, as exemplified by this case, misplacement of either can prove fatal”
4. unreliable pH testing and X ray interpretation causing misplacement
“The Healthcare Safety Investigation Branch independent report 12019/006 made recommendations in December 2020 on the placement of feeding nasogastric tubes. It found that the use of pH strips is potentially unreliable and incorrect X ray confirmation and interpretation is the most common cause of misplacement incidents”
5. lack of standardized training for decompression tube placement
“One of the recommendations made was for a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing”
6. absence of training and guidance for decompression tubes
“It appears that there is no suggested training nor national guidance in relation the placement of nasogastric decompression tubes”