A blurred hospital corridor with a healthcare professional walking away and a drip stand in the foreground.

Placement of nasogastric tubes

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This investigation report looks at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice.

Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them.

Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures implemented to tackle COVID-19 have also added to the challenges of inserting and confirming placement of NG tubes.

Reference event

We started this investigation after we were informed about the case of Fabian, a 26-year-old man who had an NG tube accidentally placed into his lungs whilst being treated in a critical care ward after a cycling accident in 2018.

The report states that he received 1450ml of ‘enteral’ feed into his lungs before it was stopped. His condition deteriorated over two days before the error with the misplaced tube was identified. The feed in his lungs was removed and he spent a few days recovering in critical care and a ward before being discharged home.

Investigation summary

Following analysis of the reference event, the investigation examined the placement and confirmation of NG tubes which is done either via pH testing or an X-ray. The investigation considered the two processes in context of the safety risks and found that misinterpretation in both contributed to placement errors.

The overall national investigation also considered the perception of safety culture related to placing NG tubes, the timeline for new technological solutions as well as reporting, regulation and procurement.

Key findings from the investigation include:

  • There is ongoing research to find a reliable design solution to reduce the risk of misplaced NG tubes but a new technological solution is not imminent.
  • There is significant variation in how existing safety standards are implemented and continually monitored.
  • Reporting NG tube related incidents to the Medicines and Healthcare products Regulatory Agency (MHRA) via their ‘yellow card scheme’ is less frequently done in comparison to NG tube related incidents reported on the National Reporting and Learning System or Strategic Executive Information System (national systems for reporting patient safety incidents).
  • The process of confirmation of correct NG tube placement using pH strips is potentially unreliable and its complexity underestimated. The investigation also identified concerns around the reliability and usability of pH strips.
  • Research suggests X-ray confirmation of NG tube placement is thought to be the most accurate method if a standard process is consistently followed. However, incorrect X-ray confirmation and interpretation is the most common cause of NG tube incidents.
  • There is no consistent process for assessing and recording competency in NG placement and confirmation using pH testing or X-rays.
  • The introduction of measures to manage COVID-19 resulted in increased challenges for NG tube insertion and confirmation of tube placement.
Investigation report