Stephen Oakes
19 Apr 2021 · Coroner Margaret Jones · Stoke-on-Trent & North Staffordshire Coroner's Court
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate product description
“The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector”
2. lack of staff training
“Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change”
3. inadequate product evaluation
“The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube”
4. failure to consider alternatives
“Nursing staff did not consider alternative action when the NG tubes were not adequately draining”
5. lack of mandatory root cause analysis training
“There is no compulsory training of clinicians required to undertake root cause analysis”
6. inadequate industry awareness of labeling issue
“This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasosgastric tube being used for decompression in an emergency situation”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination.”
This report
“(5) There is no compulsory training of clinicians required to undertake root cause analysis.”