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Robert Owens

4 Apr 2017 · Coroner Andrew Barkley · South Wales Central
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The coroner's concerns

  1. 1. misplacement of nasogastric tube without proper verification

    “The Cwym Taf University Health Board Guideline Procedure for Naso Gastric insertion and Positional Confirmation 2009 had not been updated and reviewed. It was due for review in 2012. Despite clear National Guidelines from the National Patient Safety Agency (NPSA) advocating the PH testing and x-raying of a patient after the insertion of a tube, these guidelines where never followed. The evidence revealed that it is common practice within the Health Board only to x-ray and not to follow the National”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Robert Owens · Recurance