Recurance · prevention of future deaths reports
Pre-inquest brief
Misplaced nasogastric tubes in infants
The earlier warning
Don Fernandes · 15 Dec 2020 · Darren Salter, Oxfordshire
“With reference to the RCA Report at appendix 1: Action Plan, there are a number of recommendations concerning the policy for the insertion and use”
judiciary.uk/prevention-of-future-death-reports/don-fernandes
What was promised
Stated action 1 · response to Don Fernandes (15 Dec 2020) · stated timescale: end of 2019 and beginning of 2020
“Action Plan, there are a number of recommendations concerning the policy for the insertion and use of NG tubes in infants and a recommendation that the nurse involved be reassessed for NGT competence. It appears that the action points were due for completion at the end of 2019 and beginning of 2020. In particular, I have seen the more user friendly policy and the 'at a glance' appendix that now forms part of the policy.”
judiciary.uk/…/2021-0172-Response-from-Oxford-University-Hospit…
What recurred
- 9 Jan 2025 · David Tighe · Michael Walsh · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Don Fernandes · 15 Dec 2020
“With reference to the RCA Report at appendix 1: Action Plan, there are a number of recommendations concerning the policy for the insertion and use”
Later · David Tighe · 9 Jan 2025
“At the time of [the deceased]'s death there was no separate policy for Ryles tubes, and clinicians were required to apply the modest Royal Marsden Manual guidance”
What happened next
No web check of the stated actions has been published for this chain.