Recurance · prevention of future deaths reports
Pre-inquest brief
Misplaced or removed nasogastric tube
The earlier warning
Van Tuyen · 22 Feb 2022 · Jonathan Stevens, Inner North London
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 30 Aug 2024 · Terence Clark · Graeme lrvine · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · Terence Clark · 30 Aug 2024
“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy.”
What happened next
No web check of the stated actions has been published for this chain.