Inadequate note keeping of nasogastric tube placement
Department of Health and Social Care received 4 coroners' reports about this hazard between 14 Oct 2013 and 22 Feb 2022.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 2 of the 3 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 3 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“Boards were asked to assess and address compliance issues by 21 April 2017”
Stated timescale: 21 April 2017
- 0 months later
“Common themes in all were: (a) _ Staff not being aware of the policy.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“Boards were asked to assess and address compliance issues by 21 April 2017”
Stated timescale: 21 April 2017
- 5 years 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2013 → 2017Amanda Coulthard3 years 3 months after Frederick Davidson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with staff actions concerning nasogastric tube placement and associated policies.
Frederick Davidson · 14 Oct 2013
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
Original on judiciary.uk ↗ Amanda Coulthard · 18 Jan 2017
“not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Original on judiciary.uk ↗ 2017 → 2022Van Tuyen5 years 1 month after Michael Parke · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern deaths caused by misplaced nasogastric tubes, a preventable never event. The earlier report highlights staff unawareness of policy, while the later report notes the lack of a unified approach to prevent ongoing incidents.
Michael Parke · 18 Jan 2017
“Common themes in all were: (a) _ Staff not being aware of the policy.”
Original on judiciary.uk ↗ Van Tuyen · 22 Feb 2022
“The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.”
Original on judiciary.uk ↗ 2017 → 2022Van Tuyen5 years 1 month after Amanda Coulthard · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports concern deaths caused by misplaced nasogastric tubes, a preventable never event. The earlier report highlights staff failures to follow existing policy, while the later report stresses the absence of a unified national approach to stop ongoing incidents.
Amanda Coulthard · 18 Jan 2017
“Staff not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Original on judiciary.uk ↗ Van Tuyen · 22 Feb 2022
“(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.”
Original on judiciary.uk ↗ 2013 → 2022Van Tuyen8 years 4 months after Frederick Davidson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with nasogastric tube placement leading to preventable harm. The earlier report focuses on inadequate documentation of placement, while the later report frames misplaced tubes as a never event.
Frederick Davidson · 14 Oct 2013
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
Original on judiciary.uk ↗ Van Tuyen · 22 Feb 2022
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
Stated action · timescale: 21 April 2017
“Boards were asked to assess and address compliance issues by 21 April 2017”
Stated action · timescale: 21 April 2017
“Boards were asked to assess and address compliance issues by 21 April 2017”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2013 → 2017 | 0.84 | 0.14 | Closely related · 0.90 | different |
| 2017 → 2022 | 0.83 | 0.32 | Closely related · 0.90 | different |
| 2017 → 2022 | 0.84 | 0.30 | Closely related · 0.90 | different |
| 2013 → 2022 | 0.78 | 0.32 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Department of Health and Social Care
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.