Warning over 'feeding tube risk'

All of the deaths from incorrect tube insertion happened in hospitals

Patients have been put at risk by the use of unreliable tests to ensure feeding tubes are properly inserted, the NHS safety body says.

Eleven patients have died and 13 hurt in the last two years when tubes were inserted into their lungs by mistake.

About 1m nasogastric tubes, which are fed up the nose and into the stomach, are used each year to provide liquid nutrition to patients who cannot eat.

The National Patient Safety Agency has recommended two tests be carried out.

The NPSA said the person inserting the tube should measure the stomach acidity with pH strips and in some cases carry out an x-ray.

The agency has also asked University of Birmingham researchers to look at testing methods for newborn babies - the guidelines relate to children and adults.

People have not looked at how reliable the particular tests are. These tests are not as reliable as initially thought Dr Helen Glenister

All the cases highlighted - there could have been more as the agency relies on voluntary reporting - involved tubes inserted in hospitals by doctors and nurses. One of the people who died was a child.

However, the tubes, which have been used since the formation of the NHS, are also increasingly used in residential homes and in domestic settings by trained carers.

The NPSA said unreliable tests have been relied on in the past, including the "whoosh test" which involved injecting air down the tube and checking the sound made.

If a tube is inserted into the lung, the feed builds up and eventually the lung stops working.

Warning

NPSA's director of safer practice Dr Helen Glenister said thousands of tubes are used each day without a problem.

However, she said the medical profession must be made aware that many of the tests traditionally used are not accurate.

"People have not looked at how reliable the particular tests are. These tests are not as reliable as initially thought."

Chief Medical Officer Sir Liam Donaldson added it was important to learn from the guidance issued by the agency as it could "save lives of future patients".

"Every year hundreds of thousands of patients benefit from nasogastric feeding when tubes are placed correctly and without incident.

"Incorrect position is rare, but can cause serious harm."