Frederick Davidson
14 Oct 2013 · Coroner Martin Flemimg · Surrey
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. inadequate note keeping of nasogastric tube placement
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate”
2. inappropriate use of nasogastric tube in advanced dementia
“The inappropriateness of the use of a naso gastric tube given Mr [name redacted] known history of advanced dementia and seizures”
3. gaps in clinical documentation
“Unexplained and important gaps in the clinical notes”
4. communication breakdown between junior doctor and consultant
“Breakdown in communication between the junior doctor and consultant”
5. failure to recognize pneumothorax on x ray
“The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment”
6. authorisation of feeding without documentation
“The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“Breakdown in communication between the junior doctor and consultant. - The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment”
Later report
“There appears to have been a breakdown in communication. There could be an improvement by way of standardisation of documentation”
Closely relatedConfidence 0.90 · high
This report
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
Later report
“not being aware of the policy. (b) Staff not reading the policy. (c) Staff not applying the policy.”
Closely relatedConfidence 0.90 · high
This report
“Staff's note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.”
Later report
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
Responses
No published response was found on judiciary.uk.