Van Tuyen
PFD Report
All Responded
Ref: 2022-0058
All 1 response received
· Deadline: 19 Apr 2022
Coroner's Concerns (AI summary)
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
View full coroner's concerns
(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.
(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.
Responses
Action Taken
The Department of Health and Social Care highlights existing guidance and resources related to nasogastric tube misplacement, including a patient safety alert and eLearning materials. They also mention the HSIB investigation and the awarding of funding for research on patient safety, including the reduction of never events. (AI summary)
The Department of Health and Social Care highlights existing guidance and resources related to nasogastric tube misplacement, including a patient safety alert and eLearning materials. They also mention the HSIB investigation and the awarding of funding for research on patient safety, including the reduction of never events. (AI summary)
View full response
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
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
Sent To
- Barts Health NHS Trust
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
1 of 3
56-Day Deadline
19 Apr 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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.
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.
Copies Sent To
Interested , grandchildren of the deceased
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Consequences for breaching event healthcare standards
Manchester Arena Inquiry
Regulator patient safety alerts
Duty to report external investigation findings
Morecambe Bay Investigation
Regulator patient safety alerts
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.