“It is reassuring that the Trust carried an RCA investigation which identified issues and…”

The coroner’s concerns

– 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, I 2 have seen the more user friendly policy and the ‘at a glance’ appendix that now forms part of the policy. I enquire however if there is an audit of similar incidents involving misplaced tubes in children and whether there have been any subsequent incidents resulting in harm. If there are, I enquire what if any further measures have been introduced ? (2) 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 exposure on 20 August 2019 (PICU Consultant) documented that if there was no suspicion of migration or misplacement of the NGT (coughing, choking or vomiting) then it was not necessary to perform an x-ray of the NGT position. This would avoid excess radiation from repeated x-rays. The above would not apply however if the tube had been re-sited or was suspected to have migrated. In this case an x-ray would be needed to confirm placement. It appears that the nurse in question was concerned about the number of x-rays and was made aware about the change to policy for Don Maximus but it appears that she misunderstood it and did not believe an x-ray was required in this case. There are two points that arise, firstly, there is the dilemma in terms of the need to correctly confirm the NGT position but also the need to avoid excess radiation. I enquire if there is any other method of reliably confirming the place of the NGT? I assume not as otherwise it would be routine. I understood from information provided at inquest that there are no cameras small enough that can be used to confirm the position. 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.

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, 2021-0172

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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