Don Fernandes

1. 1. misplaced nasogastric tubes in infants

   “It is reassuring that the Trust carried an RCA investigation which identified issues and lessons. There are remaining concerns however: (1) 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 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”

2. 2. inadequate confirmation of NGT placement

   “There was a further issue concerning Don Maximus' case. It was noted from statement and oral evidence that the correct position of an NGT in PICU is normally confirmed by aspirating the gastric contents and confirming it is acidic or by performing an x-ray. Measuring the pH of stomach contents is problematic if the child is on antacid medication as it may not test as acidic. I note that Don Maximus required multiple x-rays to confirm placement of the NGT and in order to reduce the need for extra”

3. 3. policy change uncertainty causing procedural confusion

   “The second point is the fact that the change to normal policy in Don Maximus case, whilst understandable and perhaps necessary, introduced an element of uncertainty particularly with regard to a nurse caring for Don Maximus for the first time as was the case here. I enquire if there are any additional measures to reduce the prospect of a similar incident occurring in future.”

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