Van Tuyen

“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”

“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”

“Common themes in all were: (a) _ Staff not being aware of the policy.”

“The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.”

“Staff not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”

“(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.”

“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”

“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy.”

“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”

“heard evidence that the time there were no guidelines about insertion of nasogastric tubes in circumstances where someone had had previous gastric surgery”