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Nurse Carrie-Ann Nash ignored the “red flag” warning signs warning that she had inserted the tube incorrectly.

Instead of inserting her feeding tube into her stomach, Nash pushed the tube into Phoebe Willis’s abdominal cavity, leaving the little girl in agony.

Little Phoebe was diagnosed with a rate genetic condition, cystinosis, as a baby, and needed the feeding tube for sustenance.

The feeding tube needs to be changed every three months, something her parents do without a problem.

Phoebe was transferred to Weston General Hospital after undergoing a procedure, and it required her tube changing.

There was no one on shift at the hospital qualified to change Phoebe’s tube. Nash was called to the hospital to help as she was a community nurse.

A misconduct tribunal hearing at the Nursing and Midwifery council heard how Nash reinserted the tube, despite being well outside the two-hour time limit for this.

Lewis MacDonald, for the NMC, previously said: “After one hour it is difficult, after two it is impossible.

“Despite this she attempted to insert the tube and this caused bleeding, this was a red flag warning. She used the tube with some force.

“She flushed it with water and the patient screamed out in pain, another red flag.”

Nash failed to seek specialist help from a doctor, even when feed was leaking from the tube, and Phoebe was sent home.

The next day the little girl was rushed to hospital. It was discovered that the tube had been inserted wrong and that a “significant amount” of milk was in her abdominal cavity. She died the same day of a blood infection, after suffering three cardiac arrests and brain damage caused by the mistake.

The panel were told how Nash should never have attempted to insert the tube into Phoebe, and how she must have done so with “some force”.

The heard that Nash ignored “red flag” warning signs when Phoebe was screaming out in pain and was bleeding.

The report from the hearing said that Nash did not understand the “seriousness of her failings” and that they felt she was at risk of repeating the fatal error.

It considered that “your grave failures, as particularised in the facts found proved, were a significant departure from the standards expected of a registered nurse and contributed to the death of a particularly vulnerable patient”, the report continued.

Nash had an “unblemished career” before this incident and has shown “considerable remorse”.

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