PEG care on 30 October
12. Mr P has concerns about how the Trust manged Miss P’s PEG care when the district nurse attended their home. Specifically, he explains the nurse rotated the balloon twice, and this caused the tube to fall out. Following this, the Trust made a referral to the specialist team to replace this after the weekend.
13. The Trust says the says the staff member’s training and skillset meant they would be expected to be able to provide care for the tube, insert the device if it became dislodged and provide the appropriate aftercare.
14. We sought clinical advice to help us carefully consider if the Trust managed Miss P’s care with the tube appropriately.
15. Our adviser explains the manual of clinical nursing procedures sets out what should happen in these circumstances. It also sets out what to do if the PEG becomes dislodged.
16. If the PEG becomes dislodged, a silicone gastrostomy stoma plug, the same size to the current tube should be pushed into the stoma. This is to keep the stoma tract patent until a new tube is inserted. A new tube should be inserted by the relevant health professional ‘as soon as possible’, which in this case would have been the HEN team (during office hours) or A&E during out of hours.
17. As this was a Saturday, it is expected that the family would have been advised to take Miss P to A&E for the tube to be reinserted.
18. However, on 30 October the family were advised to wait for the HEN team to replace the tube on Monday (two days later). They were not advised to take Miss P to A&E in line with guidance. There is an indication something went wrong here.
19. We asked our adviser about the impact of this, specifically if the Miss P’s death could have been avoided.
20. We can see the tube was successfully changed on 1 November when the HEN team attended and there was no evidence of a perforated bowel. The post mortem shows the tip of the PEG was within the stomach and not dislodged. From this we can be reassured even if the advice had been given to go to A&E, the outcome would not have changed.
21. Although the clinical evidence supports there was no direct link with Miss P’s death, our adviser explains Miss P could not have fluids or food through her tube between 30st and 1st. Our adviser says this could have caused some discomfort and possible dehydration for one day but could not have led to the very sad outcome or contributed to it.
22. We recognise Mr P has had very serious worries about these events being linked, and the evidence we have seen shows no indication of this. Although we have not seen a link to the outcome, we recognise there is still an indication a mistake was made not advising him to go to A&E. Based on this, we have spoken with the Trust to ask it to take further action, to acknowledge this and make changes so this does not happen again.
23. The Trust has agreed to carry out the above actions. We are satisfied the Trust is taking these steps to resolve the complaint, and do not need to take further action at this time.
24. We hope we have clearly explained the reasons for our decision and would like to extend our sincere condolences to Mr P for the very sad loss of Miss P.