Misplaced Nasogastric Tubes: A Never Event That Will Not Go Away

The nasogastric tube has changed little in a century. It costs a few pounds, is passed at the bedside, usually by a nurse or the most junior doctor on the ward, and NHS hospitals buy nearly a million of them a year. It is also behind one of the most persistent never events in the health service.

Alverdy and colleagues published a review of nasogastric tube indications, placement and management in JAMA Surgery on 05.08.2026 (Alverdy et al., 2026). Their conclusion is carefully worded. Indications are highly variable and often subjective, and there is growing evidence that routine use after elective gastrointestinal surgery can be reduced. That finding has medicolegal consequences the review does not set out, and they are worth drawing out here.

How often does this happen?

NHS England's provisional figures for April 2025 to March 2026 record 403 never events, of which 16 were misplaced naso- or oro-gastric tubes. The number has been broadly flat over the past decade. Figures reproduced in the 2021 Healthcare Safety Investigation Branch report show 40 such events in 2015/16, 26 in 2016/17, 22 in 2017/18 and 29 in 2018/19 (HSIB, 2021).

Set against volume, the rate is very low. HSIB estimated NHS purchasing at no fewer than 967,977 tubes each year across hospital and community settings. But that arithmetic misleads at both ends. The numerator counts only misplacements that were not caught. Tubes that reach the airway and are correctly identified before anything is given down them do not appear at all, nor do the near misses. HSIB found that incidents reported internally within trusts substantially outnumber those escalated nationally. The denominator is soft in the other direction, since tubes purchased is not the same as tubes inserted.

What the never event actually describes

This is the point most often misunderstood in pleadings. A nasogastric tube entering the trachea rather than the oesophagus is a recognised event at insertion. It can occur even with careful, experienced operators. By itself, it is not evidence of poor technique, and a claim that the tube was negligently inserted into the lung will usually fail.

The never event is misplacement into the respiratory tract that is not detected before a feed, flush or medication is administered. The event being counted is a failure to confirm.

Why the check fails

Two methods are authorised in the United Kingdom, and both have known weaknesses.

pH testing

The National Patient Safety Agency alert of March 2011 remains the governing standard. Aspirate with a pH between 1 and 5.5 permits feeding to commence.

The alert is equally clear about the methods that must not be used, and it names three. The whoosh test, the acid or alkaline test using litmus paper, and judgement based on the appearance of the aspirate are never to be used to confirm position. The whoosh test is auscultation over the epigastrium while air is injected down the tube, and it had already been discredited by repeated case reports in which it falsely confirmed a tube in the lung.

Those three prohibitions date back to the first national alert in 2005 and were reiterated in 2011. Auscultation still appears in nursing and medical notes.

HSIB found the sanctioned method itself to be unreliable in practice. CE-marked enteral pH strips from different manufacturers use different colour scales. There is no standardised process for reading a strip, nor is there a consistent assessment of whether the person reading it is competent to do so. Where training is cascaded from one member of staff to the next, errors propagate.

Radiographic confirmation

When no aspirate can be obtained or the pH is above 5.5, an X-ray is required. Metheny and colleagues reviewed fourteen national guidelines in 2019 and found unanimous agreement that radiography is the most accurate method available. Among non-radiographic methods, pH testing was the most favoured and auscultation the least (Metheny et al., 2019). According to HSIB, radiography is also the most common point of failure.

Incorrect interpretation of the film accounts for more misplacement incidents than any other single cause. There is no consistent competency assessment for the task, and in most hospitals it falls to a trainee at night rather than to a radiologist. HSIB identified inattentional blindness as a contributor. A clinician reviewing a chest X-ray for consolidation or a pneumothorax may not register a tube that is clearly in the bronchial tree. Whether the request is worded as a chest X-ray or as a specific nasogastric tube position check changes what the reporter looks for.

The prior question: was the tube needed at all?

This is where the JAMA Surgery review becomes directly useful to anyone assessing a claim. The authors accept nasogastric decompression as sound practice in small bowel obstruction uncomplicated by ischaemia or peritonitis. They are considerably less enthusiastic about routine placement after elective gastrointestinal surgery, and they say the evidence now supports reducing its use.

Enhanced recovery protocols have been moving in that direction for two decades. In much of general and colorectal practice, the routine post-operative nasogastric tube has already been abandoned. In oesophagogastric surgery, the position is less settled, and I would not criticise a surgeon who decompresses a gastric conduit after oesophagectomy.

The medicolegal consequence is straightforward. Where a tube was passed by reflex or by ward custom rather than for a stated indication, and the patient was then harmed by feed delivered into the lung, the claimant has two arguments rather than one. The second – that the intervention should never have taken place – is often the harder for a defendant to answer, because the notes rarely record why the tube was ordered.

Where breach of duty is usually found

In the cases I see, the failure clusters around a small number of recurring points.

• Feeding started on an aspirate that was never obtained, or on a pH that was never recorded
• Reliance on a prohibited test, most often auscultation, sometimes documented in terms
• An X-ray requested but feed commenced before the film was reviewed
• An X-ray obtained and misread, frequently out of hours by a clinician with no formal competency in the task
• A tube advanced, repositioned or replaced after an initially correct check, with no fresh confirmation

The last of these warrants particular attention. Initial placement is confirmed, but the tube subsequently migrates or is pulled back and re-advanced by another member of staff, and the original X-ray is treated as continuing authority. It is not.

Causation and quantum

Once feed or medication has entered the lung, causation is rarely difficult in principle. Chemical pneumonitis, secondary infection, acute respiratory distress syndrome and death are well described.

In practice, the argument centres on volume, timing and the patient's baseline. A defendant may argue that the patient was already critically ill and would have deteriorated regardless. That argument carries real weight when a small volume was given and the error was recognised within hours. It carries very little weight when the delay was measured in days. In the case that prompted the HSIB investigation, a 26-year-old man admitted after a bicycle accident received approximately 1,450 ml of feed into his airways over three days before a chest X-ray on 24.12.2018 revealed the misplacement.

Volume and delay are therefore the two key facts to establish early. They usually determine whether the claim concerns a period of avoidable intensive care or a death.

What makes the care defensible

These are the five things I look for in the records.

Where those five things are present, the defence is usually sound, even if the outcome was poor. Where the second and third are missing, as they frequently are, the defence is difficult, regardless of how careful the insertion was.

Implications for expert witnesses

The never event label carries the same trap here as with retained foreign bodies. It invites the inference that the event alone establishes negligence. It does not. The questions that decide these cases are narrower. Was there a recorded indication for the tube? Was the confirmation performed using a method sanctioned at the relevant date and by someone competent to do so? Was it repeated after the tube was disturbed?

Experts should also be mindful of the date of the care in question. The standard has changed. Care delivered before March 2011 should be judged against the 2005 alert; care delivered after July 2016 should be judged against the resource set issued with the NHS Improvement alert of that year. Applying the current standard to historical care is a common error in both directions.

Key Takeaways

Conclusion

Twenty-one deaths and seventy-nine cases of harm were reported to the NPSA between September 2005 and March 2010. Following repeated national alerts and an HSIB investigation, the annual never event count has settled at somewhere between fifteen and thirty. The interventions have plateaued rather than worked.

The most reliable protection remains the one the JAMA Surgery authors point to without saying so directly. A tube that was never passed cannot be misplaced. Where the indication is weak, the safest confirmation policy in the world is not the first line of defence.