A coroner has issued a formal warning after a 69-year-old woman died at Northumbria Specialist Emergency Care Hospital in Cramlington when NHS staff inserted a feeding tube without knowing she had previously undergone gastric bypass surgery. Ellen Victoria Floyd Taylor died on July 1, 2025, due to an infection caused by a perforation in her small intestine from the nasogastric tube.
Coroner's findings and concerns
Northumberland assistant coroner Sarah Middleton, who held an inquest in January 2026, found that Ms Taylor's altered anatomy from previous weight loss surgery was not clearly documented in her medical notes. The coroner stated that the fact of her previous gastric surgery was not known by the treating professionals. A nasogastric feeding tube was inserted on June 25, 2025, due to clinical need after Ms Taylor suffered a stroke, which she had a history of.
Over the following days, Ms Taylor experienced abdominal pain. A CT scan on June 29 revealed that the tube had caused a tear in her intestine. The coroner explained: "This was due to her altered anatomy from the previous bypass surgery. The nasogastric tube could not be placed in her stomach and over the days she has had it inserted it has caused the perforation." Ms Taylor became acutely unwell and died on July 1.
National guidelines questioned
The coroner has written to NHS England through a formal "prevention of future deaths" report, warning that national guidelines make no mention of considering previous stomach surgery when inserting a feeding tube. This document was made public this week. The coroner highlighted that because Ms Taylor's altered anatomy was not obvious from her notes, when complications began, the risk of potential perforation was not considered initially, and investigations were not undertaken promptly.
The coroner added: "The fact that she has previous surgery and her anatomy was therefore altered was not obvious from her notes. As such when complications began this was not something that was considered and investigations about potential perforation were not undertaken initially."
Trust response and changes
Northumbria Healthcare NHS Foundation Trust, which runs the hospital, conducted an "After Action Review" and identified areas of learning. The coroner noted that local guidelines have now been changed to include consultation with the on-call surgical team for guidance about insertion of the tube in these circumstances. Training has taken place, and a clinical safety message has been circulated to increase awareness.
The coroner expressed concern about wider risks: "Whilst the local NHS Trust have taken and implemented these steps my concern is that there is a wider risk, and these are circumstances that are relevant to every NHS trust nationally and there is a risk future deaths will occur unless action is taken."
A spokesperson for Northumbria Healthcare NHS Foundation Trust said: "We would like to offer our condolences to Ms Taylor's family and loved ones. We cannot discuss the situation in detail due to patient confidentiality, but we carried out our own review of what happened before the coroner's case. As outlined in the coroner's report, we have already updated our procedures, provided training, and shared clinical safety information with all staff."
NHS England has been contacted for comment.
