Rohid Shergill

1. 1. lack of parental competence with NGT use

   “Ensuring that parents of children fed in this way are completely happy with what they have to do, and understand the significance of it. There was clear confusion about whether this was the responsibility of the school nurse or the community nurses (then working separately). Urgent consideration should be given to an agreed protocol to ensure parental competence wherever an NGT is first used - in the community or in hospital.”

2. 2. inadequate information sharing between trusts

   “Information‐sharing between the two trusts - by way of shared IT and / or the use of shared care folders kept in the family home - with clear training to staff on what information should be recorded there.”

3. 3. absence of designated keyworker

   “Clear guidance on a named keyworker / lead nurse who is responsible for coordinating the care of children cared for in the community.”

4. 4. insufficient training on pH testing before medication

   “Training to physiotherapy teams regarding the importance of pH testing (or at least confirming this has been done) before administration of medication. This should be considered for other disciplines who routinely visit sick children at home and prescribe medication - such as occupational therapists / speech and language therapists.”

5. 5. reuse of syringes for pH testing causing contamination risk

   “There should be a review of the policy of syringes being used multiple times for pH testing aspirate from NGTs - and whether this results in a risk of contamination and therefore falsely reassuring results.”

Linked reports

No published response was found on judiciary.uk.