Amarbai Bhudia
12 Nov 2020 · Coroner Graeme Irvine · East London
The coroner's concerns
1. inadequate documentation of NG tube management instructions
“Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.”
2. absence of clinical instruction for NG tube management
“Nursing staff had no clinical instruction as to how to manage the NG tube.”
3. inexperienced agency staff managing NG tube
“Nursing staff dealing with the patient were agency staff without training or experience of NG tube management.”
4. failure to escalate NG tube concerns
“Concerns regarding the NG tube function were not properly escalated to clinical staff.”
Responses
2020-0232-Response-from-Barts-Health-NHS-Trust-Redacted.pdf ↗· Department of Health and Social Care and Royal London Hospital
Stated action
“In response to concerns in the department of surgery regarding the quality and content of communications about clinical instructions, an audit was designed and implemented by the junior surgery team. This identified that there was a need for a structured ward round template, and showed that implementation of a structured ward round improved communication on the ward.”
Stated action
“Nursing staff had no clinical instruction as to how to manage the NG tube A teaching session regarding Nasogastric Tube Placement was devised by the Barts Health Clinical Skills Facilitators and delivered to the teams on the wards by the Ward Managers and Professional Development nurse, and the slides used were shared by email with all staff.”
Stated action · August 2020
“The Trust's Induction Policy has been reviewed and revised (August 2020) to ensure that it includes assurances that temporary staff are competent to carry out the care and treatment of the patients they are allocated on the particular shift.”
Stated action
“A local induction guide has been produced which clearly outlines what is expected of staff working on East Ham ward. Within it are multiple examples of the process of escalation, including the nursing staff being empowered to escalate to Consultants if not getting a response from junior doctors.”