Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0058, written 22 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Feb 2022 |
|---|---|
| Reference | 2022-0058 |
| Deceased | Van Tuyen |
| Coroner | Jonathan Stevens |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for the Department Health & Social Care, 39 Victoria Street Westminster, London SW1 H 0EU 2. Chief Executive, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1FR 3. NHS England London, Skipton House, 80 London Road, London, SE1 6LH CORONER I am JONATHAN STEVENS, Assistant Coroner, for the coroner area of Inner North London 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 31 st August 2021 Assistant Coroner Stevens commenced an investigation into the death of VAN THAI TUYEN [age 96). The investigation concluded at the end of the inquest on 2nd February 2022. The conclusion of the inquest was that death was a consequence of neglect namely a failure to identify that a nasogastric tube had been misplaced before commencing feeding. The medical cause of death was: 1 (a) cavitating necrotising pneumonia (b) misplaced nasogastric tube 2. Cerebrovascular disease, hypertension, diabetes mellitus, Parkinson's disease (b) CIRCUMSTANCES OF THE DEA TH Mr Van Thai Tuyen was admitted to the Royal London Hospital on 1st August 2021 for treatment of a stroke. A nasogastric tube was inserted to administer medication and food, due Mr Tuyen being assessed as having an unsafe swallow. Despite an x-ray showing that the nasogastric tube had been misplaced into his right lung the tube was used to administer approximately 300ml of liquid feed. This caused the cavitating necrotising pneumonia from which he died. 5 CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. - (1) Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen. (2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death. (3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012. (4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country (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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th April 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested , grandchildren of the deceased. I am also under a duty to send the Chief Coroner a copy of your response. I may also send a copy of your response to any other person who I believe may find it useful or of interest The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner . 9 22nd February 2022 SIGNED .. V 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU Tuesday 29th November 2022 Jonathan Stevens Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Mr Stevens, Thank you for your letter of 22 February 2022 about the death of Mr Van Thai Tuyen. I am replying as Minister with responsibility for Health and Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Tuyen’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission (CQC). Since NHS England issued the 2016 Patient safety alert ‘Nasogastric tube misplacement: continuing risk of death and severe harm’ and accompanying resources, they have worked with partners across the healthcare system to provide additional support for local implementation of this guidance. This includes funding the Royal College of Radiologists to provide eLearning in x-ray interpretation of nasogastric tube placement, working with the British Association for Parenteral and Enteral Nutrition who published an easy reference version of key nasogastric safety checks, and working with the Nursing and Midwifery Council who added nasogastric placement to its core standards of proficiency for registered nurses. In October 2019, the Healthcare Safety Investigation Branch (HSIB) launched an investigation into nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice. HSIB published their report in December 2020, which included a recommendation that NHS England and the Department of Health and Social Care identify the process by which the NHS can commission necessary research to support improvements in patient safety, including research to confirm nasogastric tube placement. Implementation of the learning and advice from the HSIB report within the health system is ongoing. To support this, and following an open competition, the Department has awarded £25 million of funding over the next five years via the National Institute for Health and Care Research (NIHR) for research on patient safety to improve the safe delivery of health and care. The funding is for six NIHR Patient Safety Research Collaborations (PSRCs) across England to help improve understanding and resolution of patient safety challenges. The PSRCs will From Maria Caulfield MP Parliamentary Under Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU undertake high-quality translational, applied and health services research on patient safety that addresses strategic patient safety challenges within the health and care system, aligned with NHS England’s National Patient Safety Strategic Research Needs 2022/23. Crucially, the PSRCs’ work will include research into the reduction of never events. I hope this response is helpful. Thank you for bringing these concerns to my attention. Kind regards, MARIA CAULFIELD
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