David Tighe
PFD Report
All Responded
Ref: 2025-0158
All 1 response received
· Deadline: 22 May 2025
Coroner's Concerns (AI summary)
The trust lacked a specific Ryles tube policy, leading to inconsistent care and documentation. A subsequent review was too narrow, missing critical observations, documentation failures, and unrecorded family concerns.
View full coroner's concerns
Concerns directed to Oxford University Hospitals NHS Foundation Trust CONCERNS Absence of a Ryles tube policy:
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (‘NG feeding tube policy’), which provided limited advice. Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death. Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but several staff were unaware of such a document existing for Ryles tubes, and no such Ryles Tubes records were ever disclosed. Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring. At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023. It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required. The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure. Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of the medical records across five different areas, undertaken in a highly pressured environment. The Structured Review consequently overlooked considering several issues including: (i) (ii) (iii) (iv) missing bile drainage entries. missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021). the absence of Repeat Position Checks for the Ryles tube. the absence of any written record of family concerns that were raised with a ward sister. Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review. That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance. Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
1. At the time of David’s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust’s “Insertion, Use and Care of Nasogastric Feeding Tubes in Adults: Policy and Procedure”, October 2018 (‘NG feeding tube policy’), which provided limited advice. Evidence was given that a Ryles tube policy was required and that there was motivation at the Trust to provide one, albeit none has been forthcoming in the 20 months since David’s death. Evidence was also given that an NG tube “Position Record” for recording “Repeat Position Checks” was in use for Ryles tubes (similar to the “Nasogastric Feeding Tubes Position Record - Repeat Position Checks” document at Appendix 11 / page 53 of 55 of the Trust’s NG feeding tube policy), but several staff were unaware of such a document existing for Ryles tubes, and no such Ryles Tubes records were ever disclosed. Expert evidence was given that it was suboptimal care not to have a specific policy for the management of Ryles tubes given the risks associated with such an invasive procedure that required ongoing monitoring. At the time of the inquest, the Trust’s expressed intention was to provide a Ryles tube policy, and assistance was said to have been requested from the Shelford Group (an external body), although conversations about such a policy were said to have started within the Trust itself, as early as April or May of 2023. It is therefore unclear whether a Ryles tube policy would ever be produced notwithstanding one appears to be accepted as being required. The absence of policy where a need has been identified creates an obvious risk of death to future patients, due to the absence of guidance and procedure to assist clinicians undertaking such an invasive procedure. Use of a narrowly focussed structured review by a treating clinician:
2. On 18.03.2023 the Trust undertook a Structured Review to consider learning from David’s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of the medical records across five different areas, undertaken in a highly pressured environment. The Structured Review consequently overlooked considering several issues including: (i) (ii) (iii) (iv) missing bile drainage entries. missing clinical observations contrary to Trust policy (“Recognising the Acutely Ill and Deteriorating Adult Patient (RAID) Policy, April 2021). the absence of Repeat Position Checks for the Ryles tube. the absence of any written record of family concerns that were raised with a ward sister. Evidence was given by an author of the Structured Review that he considered its scope was in fact too limited, and in future, he would advise suspending such a narrow review. That author was also a clinician involved with David’s care in spite of the potential for conflict being correctly raised with the Trust in advance. Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.
Responses
Action Taken
Oxford University Hospitals NHS Foundation Trust has strengthened mortality review processes by formalising feedback of family concerns and modifying the Serious Judgement Review template to address concerns about scope, focus, or conflicts of interest. (AI summary)
Oxford University Hospitals NHS Foundation Trust has strengthened mortality review processes by formalising feedback of family concerns and modifying the Serious Judgement Review template to address concerns about scope, focus, or conflicts of interest. (AI summary)
View full response
Dear Mr Walsh Regulation 28 Report/Prevention of Future Deaths Inquest into the Death of Mr David Vincent Tighe
Following the death of Mr David Vincent Tighe, and subsequent inquest hearing from Wednesday 11 December - Friday 13 December 2024 and Monday 16 December – Wednesday 18 December 2024, I write as CEO of Oxford University Hospitals NHS Foundation Trust (OUH), to provide a response to your Regulation 28 Report dated 9 January 2025. I would like to start by expressing to Mr Tighe’s family how sorry I am for their loss. Mr Tighe had been diagnosed with adenocarcinoma of the gastro-oesophageal junction in November 2022. He commenced chemotherapy treatment with a life expectancy of at least a year, and subsequently suffered chemotherapy-induced enterocolitis, which was a known complication of his treatment and related symptoms requiring admission to the Oncology Ward, Churchill Hospital on 2 February 2023. You recorded a narrative conclusion on 18 December 2024 as follows: “David (Tighe) died due to complications of treatment for chemotherapy-induced enterocolitis; contributed to by Neglect.” The medical cause of death was confirmed after hearing evidence from OUH clinicians and external nursing expert by you to be: 1a Sepsis due to Bronchopneumonia 1b Enterocolitis with Paralytic Ileus 1c Metastatic Adenocarcinoma of Oesophagus treated with Chemotherapy
2) Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease
In your conclusion you set out two areas of concern, and for each I can provide the following additional information:
1. Absence of a Ryles Tube Policy There is no nationally recognised policy for wide bore nasogastric (Ryles) tubes for aspiration drainage. The existing OUH policy is for nasogastric (NG) tubes when used for feeding. Current practice for insertion of a wide bore tube is based on the Royal Marsden manual of clinical and cancer nursing procedures. Only one of the 9 similar Trusts who we approached has a policy which is virtually identical to the Royal Marsden manual. The Oncology Matron has set up a working group to review current practice, evaluate external resources and produce a Trust wide policy. The policy will set out the Trust standards for managing patients with Ryles Tubes for aspiration drainage. The working group includes nursing and medical staff across the organisation including anaesthetics, surgery, oncology and gastroenterology representatives. The first meeting was held on 3 February 2025. The policy will be presented to the OUH Clinical Policy Group by April 2025 and a Trust wide safety message will be communicated to all staff which will include the link to this policy. The publication of the policy will be followed by training of the appropriate staff through ward-based learning delivered by clinical educators.
2. Use of a narrowly focussed Structured Review by a treating clinician The Trust has a robust process for training clinicians in performing Structured Judgement Reviews (SJRs). The training highlights the need to review the whole case record including the nursing records. It directs the reviewer to contact any individual or team if there are concerns about the quality of care provided. There is no limit put on the length of time to undertake an SJR. Over 230 clinicians within OUH have been trained to date. Since this case we have strengthened our mortality review processes in two ways. Firstly, we have formalised the process for feeding back family concerns to the clinical team and incorporating these into the mortality review. The Medical Examiner Officers speak to every bereaved family of a patient who dies in OUH and feed back, in a structured format, any concerns from the family about the care of the deceased. This feedback is directed to the Divisional governance team and responsible clinical team who must then address this within the mortality review. Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.
In addition to the actions above, the learning from this case will be presented on 5 March at Oncology Clinical Governance meeting and will also be presented at the OUH Clinical Governance Committee and the OUH Mortality Review Group over the next 2 months. I hope that this response will reassure you that we have taken your concerns very seriously and implemented appropriate actions following this inquest.
Following the death of Mr David Vincent Tighe, and subsequent inquest hearing from Wednesday 11 December - Friday 13 December 2024 and Monday 16 December – Wednesday 18 December 2024, I write as CEO of Oxford University Hospitals NHS Foundation Trust (OUH), to provide a response to your Regulation 28 Report dated 9 January 2025. I would like to start by expressing to Mr Tighe’s family how sorry I am for their loss. Mr Tighe had been diagnosed with adenocarcinoma of the gastro-oesophageal junction in November 2022. He commenced chemotherapy treatment with a life expectancy of at least a year, and subsequently suffered chemotherapy-induced enterocolitis, which was a known complication of his treatment and related symptoms requiring admission to the Oncology Ward, Churchill Hospital on 2 February 2023. You recorded a narrative conclusion on 18 December 2024 as follows: “David (Tighe) died due to complications of treatment for chemotherapy-induced enterocolitis; contributed to by Neglect.” The medical cause of death was confirmed after hearing evidence from OUH clinicians and external nursing expert by you to be: 1a Sepsis due to Bronchopneumonia 1b Enterocolitis with Paralytic Ileus 1c Metastatic Adenocarcinoma of Oesophagus treated with Chemotherapy
2) Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease
In your conclusion you set out two areas of concern, and for each I can provide the following additional information:
1. Absence of a Ryles Tube Policy There is no nationally recognised policy for wide bore nasogastric (Ryles) tubes for aspiration drainage. The existing OUH policy is for nasogastric (NG) tubes when used for feeding. Current practice for insertion of a wide bore tube is based on the Royal Marsden manual of clinical and cancer nursing procedures. Only one of the 9 similar Trusts who we approached has a policy which is virtually identical to the Royal Marsden manual. The Oncology Matron has set up a working group to review current practice, evaluate external resources and produce a Trust wide policy. The policy will set out the Trust standards for managing patients with Ryles Tubes for aspiration drainage. The working group includes nursing and medical staff across the organisation including anaesthetics, surgery, oncology and gastroenterology representatives. The first meeting was held on 3 February 2025. The policy will be presented to the OUH Clinical Policy Group by April 2025 and a Trust wide safety message will be communicated to all staff which will include the link to this policy. The publication of the policy will be followed by training of the appropriate staff through ward-based learning delivered by clinical educators.
2. Use of a narrowly focussed Structured Review by a treating clinician The Trust has a robust process for training clinicians in performing Structured Judgement Reviews (SJRs). The training highlights the need to review the whole case record including the nursing records. It directs the reviewer to contact any individual or team if there are concerns about the quality of care provided. There is no limit put on the length of time to undertake an SJR. Over 230 clinicians within OUH have been trained to date. Since this case we have strengthened our mortality review processes in two ways. Firstly, we have formalised the process for feeding back family concerns to the clinical team and incorporating these into the mortality review. The Medical Examiner Officers speak to every bereaved family of a patient who dies in OUH and feed back, in a structured format, any concerns from the family about the care of the deceased. This feedback is directed to the Divisional governance team and responsible clinical team who must then address this within the mortality review. Secondly, we have modified the SJR template to ask the author if they have any concerns about the scope or focus of the review, giving them an explicit opportunity to raise any concerns which can then be addressed proactively by the Trust through providing additional support. Prior to completing the review, the reviewer will also be asked to confirm whether they have any conflict of interest such as having been involved in the care of the patient. This will provide stronger assurance that all reviews investigate deaths without restriction in scope, time pressure or appearance of conflict or bias.
In addition to the actions above, the learning from this case will be presented on 5 March at Oncology Clinical Governance meeting and will also be presented at the OUH Clinical Governance Committee and the OUH Mortality Review Group over the next 2 months. I hope that this response will reassure you that we have taken your concerns very seriously and implemented appropriate actions following this inquest.
Sent To
- Oxford University Hospitals NHS Foundation Trust
Response Status
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56-Day Deadline
22 May 2025
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
The inquest into the death of Mr David Vincent Tighe, aged 59, was opened on 26th April 2023. The investigation concluded at the end of the inquest on 20th December 2024. The medical cause of death was: Ia Ib Ic II Sepsis due to Bronchopneumonia Enterocolitis with Paralytic Ileus Metastatic Adenocarcinoma of Oesophagus Treated with Chemotherapy Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease The Narrative conclusion to the inquest was: David died due to complications of treatment for chemotherapy-induced enterocolitis; contributed to by Neglect.
Circumstances of the Death
David was a 59-year-old man who had been diagnosed with adenocarcinoma of the gastro-oesophageal junction in November 2022. With chemotherapy treatment his prognosis was at least a year, and he was being treated with the intention of prolonging his life. He subsequently suffered chemotherapy-induced enterocolitis, which was a known complication of his treatment, and related symptoms required his admission to Churchill hospital on 02.02.2023. During treatment in hospital, David suffered three instances of aspiration of bile into his lungs when he was laid flat, that should have been avoided. The Ryles tube being used to drain bile from his stomach, and the amount of bile being drained, were insufficiently monitored, and the Ryles tube became displaced following an episode of vomiting, on 08.02.2023, causing ineffective and/or partial drainage over several hours. He was also noted to have bile in his mouth on the morning of 09.02.2023. There was no discrete policy in place for the management of Ryles tubes, and no repeat position check forms were used, although they were said to exist. Had displacement been recognised in a timely manner and/or had the presence of bile in David’s mouth been escalated in a timely manner, all events of aspiration should have been avoided, by virtue of the Ryles tube being repositioned or replaced to provide effective drainage; and/or by virtue of advice being given not to lay David flat, or to do so with particular caution. Instead, no particular caution was taken when laying David flat and he suffered aspiration which contributed in a more than minimal way to bronchopneumonia and sepsis from which David died on 11.02.2023.
Action Should Be Taken
in relation to the concerns above.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.