Chelsea and Westminster Hospital NHS Foundation Trust

6. Mrs Q complains that when her husband was admitted to the Trust with a suspected small bowel obstruction on 24 December 2021, staff did not drain his collection bag from his NG tube from 8.30pm on the night of 29 December until 10.30am the next day. As a result, his NG tube came out of place and caused acid to go onto his lungs and he developed pneumonia (inflammation of the lungs).

7. Mrs Q says the Trust’s actions caused her husband to experience a painful and traumatic death in January 2022. She says that having to witness the circumstances of his death has left her and her daughters traumatised.

8. As an outcome to her complaint, Mrs Q wants the Trust to acknowledge the failings in her husband’s care, an apology, service improvements and a financial payment.

9. Mr Q was in his seventies. He had Parkinson’s disease (a condition affecting the brain causing tremors, slow movement and stiff muscles) and a rare neurological condition that can cause problems with balance, movement, vision, speech and swallowing.

10. Emergency department (ED) staff thought Mr Q had a small bowel obstruction, so he was admitted to the Trust on 24 December 2021. Surgery was not considered appropriate because of Mr Q’s overall poor condition at the time. Mr Q had an NG tube fitted and began palliative treatment to ease his symptoms.

11. Staff moved Mr Q to a side room for more privacy on 29 December. From 8.30pm to 10.30am on 30 December staff did not drain Mr Q’s collection bag. When observed at 10.30am he was coughing, vomiting and the NG tube had come out of place. After further investigations staff found he had inhaled stomach acid into his lungs while vomiting, which caused him to develop pneumonia.

12. Sadly, Mr Q died in January 2022.

16. Mrs Q believes that staff should have drained her husband's acid collection bag and checked on his wellbeing every two to four hours during the night of 29 December. Before this she says his bag was drained every two to four hours.

17. The Trust’s complaint response says the collection bag and NG tube was checked at 7pm on 29 December, when 20ml of fluid was recorded. Staff also completed regular routine observations at 8.21pm and 9.13pm and at 5.57am and 10.30am on 30 December.

18. Staff checked the collection bag again at 11am on 30 December. The Trust says the collection bag contained 470ml of fluid. The Trust accepts the NG tube and collection bag should not have been left unchecked for such a long period of time.

19. Section 5.6 of the NMC Standards say that staff should, ‘insert, manage and remove oral/nasal/gastric tubes’.

20. There is no national guidance to say how often to check a collection bag.

21. In the absence of national guidance, our nursing adviser explains that NG tubes should be checked regularly to make sure there are no complications such as blockage, aspiration (gastric contents entering the lungs) and displacement. They say drainage volume should be measured for fluid balance purposes and to guide when the tube is no longer needed.

22. Typically, NG tubes are monitored at least four hourly and in cases where gastric contents are high, this could be as regular as every 30 minutes to make sure the patient does not choke. The timing of this would be dependent on the volume of aspirate and the patient. Mr Q was a high-risk patient due to his condition and being unable to swallow.

23. There is reference to monitoring of the NG tube in the records, but it is not structured or regular. Section 1.16 of the NMC Standards says staff should demonstrate the ability to keep complete, clear, accurate and timely records. This means the records should clearly show when Mr Q’s NG tube was placed and how often the contents were drained and monitored. From the information in his medical records, we cannot say if staff appropriately monitored and recorded the NG tube and collection bag.

24. We considered the records and see that on 28 December, staff recorded Mr Q’s aspirate at 50ml over a 24-hour period. At 2.50pm on 29 December staff recorded Mr Q’s aspirate volume at 550ml. There is also an entry in the records at 4.18pm on 29 December that drainage from the NG tube was 500ml in the last 24 hours. This does not match with what the Trust said in its complaint response. Despite the significant increase and high volume of aspirate documented on 29 December, there is no evidence of any extra checks of the NG tube until 10.30am on 30 December where records show a nurse was going to check the NG. Mr Q had been vomiting and there was 200ml in the collection bag. Further examination from staff found the NG tube had become displaced and was not draining. They reinserted it and another 470ml of aspirate was immediately drained.

25. As Mr Q’s NG tube was not checked for over 20 hours, staff did not act in line with section 5.6 of the NMC standards that say nurses are responsible for monitoring the NG tube. This a failing. Although there is no guidance to say how regular NG tube checks should be, taking account of our clinical advice we would expect monitoring to take place at least every four hours, unless medical advice said otherwise.

26. We go on to consider the impact of this failing.

27. As a result of the irregular monitoring of Mr Q’s NG tube and collection bag, Mrs Q says he aspirated gastric content onto his lungs, developing into pneumonia and causing his death to be more painful and traumatic.

28. Our nursing adviser says aspiration is common even in healthy patients. Mr Q was already at an increased risk of aspiration pneumonia due to his condition and being unable to swallow, along with the vomiting he experienced from the small bowel obstruction. The NG tube was used to reduce the risk of aspiration by draining gastric contents off the stomach, but there would still be a risk. But, our geriatrician adviser confirms regardless of any risk, if the NG is not working, the contents of the stomach can build up, causing the patient to vomit.

29. Mr Q did vomit and aspirate in the morning of 30 December. But, it is impossible for us to know exactly when Mr Q’s NG tube came out of place, when he started vomiting or how long it had been going on for before the nurses checked at 10.30am.

30. Our colorectal adviser says that when an NG tube comes out of place, from the end of the bed it may look like the NG tube is in place but careful inspection would show that it is not working or it is even curled up at the back of the patient’s throat. A badly placed NG tube is the same as having no NG tube in place but also with having the added irritation of a plastic tube in the nose/back of the mouth. It is not possible for us to say when the NG tube came out of place, but we think it is likely that Mr Q started vomiting and aspirating in the five-hour window from 5.30am, when staff completed routine observations, and 10.30am.

31. As Mr Q was at a high risk of aspiration due to his condition, we think there were missed opportunities (within the five-hour window) to drain Mr Q’s collection bag and make sure the NG tube was in place. This may have prevented him vomiting and the tube coming out of place.

32. Although we have established that Mr Q was at an increased risk of aspiration and developing pneumonia, the lack of monitoring caused Mr Q’s stomach contents to build up and for him to vomit. Due to Mr Q’s condition, he had no way of telling staff he was feeling unwell or that there may be an issue with the NG tube. Our geriatrician adviser confirms that aspirating vomit into the lungs causes aspiration pneumonia.

33. If the NG tube had been monitored and managed more often, our colorectal adviser says it is likely that Mr Q would have been more comfortable towards the end of his life because there is a chance he may not have vomited causing him to aspirate and develop aspiration pneumonia.

34. To summarise, we cannot rule out that Mr Q would not have aspirated if the NG tube and collection bag was checked more often. But, if checks were completed more often, we know the NG tube coming out of place and Mr Q’s vomiting would have been found sooner which may have improved his discomfort in his final days. We realise the degree of uncertainty around not knowing this will be distressing to Mrs Q and this is an injustice to her.

1. We have carefully considered Mrs Q’s concerns about the care Chelsea and Westminster Hospital NHS Foundation Trust (the Trust) gave to her husband, Mr Q, during the night of 29 and 30 December 2021.

2. We found failings with how regularly staff completed checks on Mr Q’s nasogastric (NG) tube and aspirate collection bag (collection bag). An NG tube is a small flexible plastic tube that is passed down through the nose, down the back of the throat and into the stomach. It is used to collect stomach contents (aspirate) for people who cannot swallow and the contents are drained into a collection bag.

3. While we cannot say if the lack of checks would have affected the sad outcome, we can see there was a missed opportunity to drain Mr Q’s collection bag and make sure the NG tube was in place. This left the family with questions about whether there could have been a different outcome. We partly uphold the complaint.

4. We can see the Trust recognises it should have checked Mr Q more often, but we do not think it has identified the reasons why things went wrong or shown learning to give reassurance that it would not happen again.

5. We have made recommendations for the Trust to acknowledge the impact of the failing we found, to apologise for the distress it caused Mrs Q and her family and to provide an action plan showing the actions it will take to make sure learning has been taken from these events. We will also ask the Trust to pay Mrs Q £950.

35. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.

36. Our principles say that public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service.

37. In line with this, we recommend that within four weeks of the date of our final report the Trust should:

• acknowledge the failing with monitoring we have found and the impact this had on Mr and Mrs Q • apologise to Mrs Q for the distress caused by the failing.

38. Within eight weeks of the date of this report the Trust should create an action plan that sets out what it will do (or what it has already done) to make sure that staff appropriately monitor NG tubes and drainage bags. The action plan should say who is responsible for each action, when it will be completed and how the impact of the actions are being monitored.

39. The Trust should share a copy of the action plan with us, Mrs Q, the Care Quality Commission and NHS Improvement.

40. Our principles state that public organisations should ‘put things right’ and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.

41. To decide on a level of financial payment, we review similar cases where similar injustice has happened, along with our severity of injustice scale. Following this review, we have decided that within six weeks of the date of our final report the Trust should:

• pay Mrs Q £950 in recognition of the degree of uncertainty caused by staff not monitoring the NG tube and collection bag as they should have, meaning Mrs Q cannot be sure her husband’s discomfort in his final days could have been avoided.