David Tighe
9 Jan 2025 · Coroner Michael Walsh · Oxfordshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. absence of Ryles tube policy
“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, and/or note that the practice consideration and care requirements for Ryles tubes were not dissimilar to that for nasogastric tubes used for enteral administration, as per the Trust's”
2. limited structured review
“On 18.03.2023 the Trust undertook a Structured Review to consider learning from [the deceased]'s death. Evidence was given that the Structured Review was intended to be narrow in focus, as opposed to a more comprehensive serious incident report. As a result, it did not involve taking information from staff, but was a 2-hour review of the medical records across five different areas, undertaken in a highly pressured environment.”
3. inadequate investigation of incidents
“Any inability to adequately investigate such incidents, without undue restriction in scope, without time pressure, and without any appearance of conflict or bias, creates a risk of death to future patients, as oversights or omissions in care, policy or procedure that may be missed by a narrow review, may remain unidentified and unremedied.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“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”
This report
“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”