Nasogastric tube errors remain one of the clearest examples of a preventable patient safety failure. A tube intended to pass into the stomach can instead enter the airway, lung, or pleural space. If food, fluids, or medication are then administered, the consequences may be catastrophic.
Across the NHS, feeding through a misplaced nasogastric tube has long been treated as a “never event” because the risk is well understood and established safety checks exist to prevent it. A never event is not simply an unfortunate complication; it is a serious, largely preventable incident that should not occur if nationally recognised safeguards are properly followed.
From a legal perspective, claims involving misplaced NG tubes often turn on straightforward questions: was correct verification carried out, was it properly documented, was the result interpreted by someone competent to do so, and should feeding, fluids, or medication have been withheld until the position was safely confirmed?
To examine the issue in more detail, this article is divided into five sections:
- How nasogastric tubes are used in clinical care
- Why misplaced NG tubes cause serious harm
- Safe placement and verification standards
- When NG tube errors may amount to negligence
- Evidence, compensation and next steps
How Nasogastric Tubes Are Used in Clinical Care
A nasogastric tube, often called an NG tube, is a fine tube passed through the nose, down the throat and oesophagus, into the stomach. It is commonly used to provide nutrition, hydration, and medication when swallowing is unsafe or oral intake is inadequate.
That may arise after a stroke, during critical illness, following major surgery, or in patients with neurological disease (including acquired brain injury). It may also be used where there is a significant risk of aspiration when eating or drinking normally. In many hospital settings, NG tubes are inserted at the bedside by trained clinicians or nursing staff.
Although insertion is routine, it is never risk-free. Even an apparently uncomplicated placement still requires formal confirmation before use. A tube that looks secure externally may, nevertheless, be in the wrong position internally.
Where longer-term enteral feeding is anticipated, clinicians may consider alternatives such as a gastrostomy tube, depending on the patient’s overall condition, prognosis, and risk profile. particularly following serious surgical complications or neurological injury.
Why Misplaced NG Tubes Cause Serious Harm
The principal danger is inadvertent placement into the trachea, bronchi, lung or pleural cavity rather than the stomach. If food, water or medication is administered through a misplaced tube, substances intended for the gastrointestinal tract can enter the lungs or chest cavity.
This may lead to:
- Pneumothorax
- Aspiration pneumonia
- Chemical pneumonitis
- Pleural infection or empyema
- Respiratory deterioration
- Sepsis (and subsequently, complications associated with delayed sepsis treatment)
- Cardiac arrest
- In severe cases, death
Many of these incidents are avoidable. Investigations repeatedly identify the same underlying failures: poor checking processes, missed abnormal X-ray findings, inadequate documentation, communication breakdowns during handover, and use of unsafe or outdated confirmation methods.
Because the mechanism of harm is well known, providers are expected to maintain robust systems that minimise the risk of first-use errors and ensure that any uncertainty is resolved before the tube is used.
Safe Placement & Verification Standards
Decision to Insert
Before insertion, clinicians should confirm that NG feeding is clinically appropriate and consistent with the patient’s treatment goals. Relevant risks should also be considered, including reduced consciousness, impaired swallow, upper airway abnormalities, oesophageal obstruction, previous surgery, facial trauma or skull base injury.
The rationale for insertion, available alternatives, and any significant risks should be recorded in the notes. The plan for confirming tube position should also be clear, particularly where the patient is high-risk or difficult to assess.
Insertion and Initial Checks
An appropriate tube should be selected and the intended insertion depth estimated using accepted measurement methods. Once inserted, the external centimetre marking at the nostril should be documented and the tube secured.
That external length becomes important later, as unexpected movement may indicate displacement. Good documentation should identify who inserted the tube, when it was inserted, the type of tube used, the recorded external length, and how placement was checked.
Confirmation Before First Use
No feed, water, or medication should be given until gastric placement has been confirmed using approved methods.
The usual first-line bedside check is aspiration with CE-marked pH paper that gives a numeric result. Where the reading is within the accepted gastric range, feeding may proceed if the wider clinical picture is consistent.
If aspirate cannot be obtained – or the result is inconclusive – feeding should not begin. In such instances, further assessment may be required, including repositioning attempts or radiographic confirmation. Uncertainty should be escalated rather than resolved by assumption or informal reassurance.
Radiographic Confirmation
Where imaging is needed, the full course of the tube and tip should be visible. Interpretation must be carried out by staff who are trained and competent to do so. Errors in radiology interpretation are a recurring feature of claims involving diagnostic mistakes in hospital care.
A safe reading generally requires confirmation that the tube follows the oesophagus, crosses the diaphragm appropriately, and terminates in the stomach rather than the respiratory tract.
If there is any doubt, use should be deferred until the uncertainty is resolved. Errors in X-ray interpretation are a recurring feature in NG tube incidents. A tube may be visibly misplaced on imaging but still wrongly documented as safe to use, which is why training, supervision and escalation pathways are essential.
Ongoing Checks
Verification does not end after first use. Tube position may change following coughing, vomiting, retching, patient movement, transfer between wards, or accidental traction.
Before each administration, staff should inspect the fixation and check the external marking. The position must be reconfirmed before further use if displacement is suspected. Reconfirmation is also required where there has been any event likely to have moved the tube, or where the external length has changed unexpectedly.
Unsafe Practices That Continue to Cause Errors
Some methods have repeatedly been shown to be unreliable and should not be used as sole confirmation techniques.
Examples include:
- The “whoosh test” after air insufflation: Air is pushed down the tube and staff listen over the stomach for sound.
- Judging by aspirate appearance alone: Tube fluid is checked by colour or texture only.
- Bubble tests in water: The tube end is placed in water to look for bubbles.
- Use of non-approved litmus paper: Standard litmus paper does not give the accurate numeric pH reading required.
- Assuming the absence of coughing or respiratory distress means safe placement: Some patients may show few or no obvious signs even when a tube is misplaced.
- Feeding after an equivocal or undocumented check: Feed starts despite unclear or unrecorded confirmation of tube position.
These practices can create false reassurance. In negligence claims, reliance on outdated or prohibited methods is often difficult to defend, particularly where national guidance and local policies required safer checks.
When NG Tube Errors May Amount to Clinical Negligence
Of course, not every complication involving an NG tube results from negligence. Some patients, for instance, are critically unwell or anatomically complex. A claim will only arise when avoidable failings caused injury.
Four legal elements usually need to be established.
1. Duty of Care
Hospitals and treating clinicians owe patients a duty to provide care that meets a reasonable professional standard. In NHS and private hospital settings, this is rarely disputed.
2. Breach of Duty
The claimant must show that care fell below that standard. In NG tube cases, examples may include:
- Feeding before confirmation of gastric placement
- Administering medication or fluids before safe tube position was confirmed
- Misreading an X-ray
- Failing to document verification
- Using prohibited checking methods
- Not rechecking after likely displacement
- Poor handover between teams
- Allowing staff without appropriate training or supervision to confirm placement
- Failing to escalate uncertainty before the tube was used
3. Causation
It must then be shown that the breach caused harm. For example, had feeding been withheld pending proper confirmation, lung injury or infection may have been avoided.
Causation can be more complex where a patient was already seriously ill. Independent medical evidence is often required to distinguish harm caused by the NG tube error from the underlying condition, especially following treatment in intensive care.
4. Damage
Compensable harm may include physical injury, prolonged admission, intensive care treatment, psychological trauma, financial loss, or bereavement in fatal cases. In some circumstances, families may also become involved in the inquest process follow a patient death.
Governance & Duty of Candour
Where serious harm occurs, providers are expected to investigate promptly through internal governance processes. That includes root cause analysis and identification of corrective actions. It may also include review of training, staffing, handover, radiology reporting processes and compliance with local NG tube policies.
The statutory Duty of Candour may also apply. This requires openness with the patient or family, an apology, an explanation of known facts, and updates as investigations progress. Notably, an apology is not the same as an admission of liability in law.
In serious or fatal cases, families may also be involved in NHS complaint processes, internal patient safety investigations, inquests, or regulatory referrals. These processes can provide explanations and learning, but they are separate from a negligence claim against the hospital.
Evidence, Compensation & Next Steps
Where negligence is suspected, early evidence is important. Key records often include insertion notes, observation charts, medication administration records, radiology images, incident reports, handover documentation, and internal investigation findings.
Compensation depends on the severity of injury and the losses caused. Claims may include damages for pain and suffering, additional treatment, rehabilitation, lost earnings, care needs, and future support.
If a family has lost a loved one, further claims may arise on behalf of the estate or dependants, depending on the circumstances.
Making a Misplaced NG Tube Claim
If you or a relative suffered harm after feeding or medication was given through a wrongly placed nasogastric tube, legal advice can help clarify whether substandard care played a role.
Our specialist clinical negligence solicitors can advise on the strength of a potential claim. Contact our team today for free, no-obligation advice.