Public Health Link
From the Chief Medical Officer for Wales
Distribution:
As below
From:
Dr Tony Jewell
Chief Medical Officer Wales
Welsh Government
Cathays Park
Cardiff CF10 3NQ
Date:
Reference:
Category:
Title:
What is this about:
Why has it been sent:
26th March 2012
CMO(12)
Non urgent (cascade within 48 hours)
Coroner’s Rule 43 letter regarding nasogastric
tube placement
Full details are set out below.
For your information and to pass on to
Colleagues
To:
Chief Executives, Local Health Boards/ Trusts
Medical Directors, Local Health Boards/ Trusts
Directors of Nursing, Local Health Boards/ Trusts
Directors of Therapies and Health Science
Directors of Public Health
For Information:
Hospitals in the independent sector in Wales
Wales Patient Safety Managers
HIW
CSSIW
Assistant Directors of Patient Safety
Dear Colleague
CORONER’S RULE 43 LETTER REGARDING NASOGASTRIC TUBE
PLACEMENT
Mary Hassell, HM Coroner, Cardiff has written to me following the death of a
patient hastened by feeding via a misplaced nasogastric tube. The Coroner’s
verdict was that the misplacement was not detected because the chest x-ray
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taken after placement was displayed in date but not time order on a hospital
computer system so the wrong image was checked.
Misplaced nasogastric tubes leading to death or severe harm are ‘Never
Events’ and the National Patient Safety Agency (NPSA) has issued three
alerts on reducing the harm caused by misplaced nasogastric tubes.
A further alert about harm from flushing of nasogastric tubes before
confirmation of placement was recently issued on 22 March. It is important
that organisations implement these alerts and ensure all staff responsible for
checking initial placement of nasogastric tubes are aware of the necessary
actions.
Dr Owen Crawley, Chief Scientific Adviser (Health) has also written to all
Radiology Departments in NHS Wales advising them of the potential problem
and requesting that local systems are checked to ensure the correct image is
used and images are displayed in chronological order.
Mr Andrew Griffiths, Chief Information Officer (Wales) at NWIS has written to
all NHS organisations requesting that they check their quality and safety
arrangements to ensure that any ‘local’ clinical portals / information
technology systems are; displaying on screen, in a chronological order, the
date and time an image (x-ray, CT or MRI) has been taken. Organisations
should report results through their governance committees and any significant
risks should be shared with NWIS.
ACTION POINTS
All NHS Wales organisations must ensure:
1. the NPSA alerts on misplacement of nasogastric tubes are implemented;
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=129640
http://www.nrls.npsa.nhs.uk/resources/?entryid45=133441
2. local systems are checked to ensure the correct image is used and images
are displayed in chronological order.
3. quality and safety arrangements are checked to ensure that any ‘local’
clinical portals / information technology systems are; displaying on screen,
in a chronological order, the date and time an image (x-ray, CT or MRI)
has been taken. Organisations should report results through their
governance committees and any significant risks should be shared with
NWIS.
Yours sincerely,
DR TONY JEWELL
Chief Medical Officer Wales
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