Terence Clark
30 Aug 2024 · Coroner Graeme lrvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. removal and loss of NG tube
“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.”
This report
“Despite Mr [name redacted] having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr [name redacted] airway at autopsy The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy.”