“2”

The coroner’s concerns

– 1. 2. 3. 4. 5. 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. 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. Clear guidance on a named keyworker / lead nurse who is responsible for coordinating the care of children cared for in the community. 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. 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2016-0364

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0