The Healthcare Safety Investigation Branch (HSIB), an investigative body that conducts independent investigations of patient safety concerns in NHS-funded care across England, published a report today on the placement of nasogastric tubes. This was well timed, coming just weeks after BAPEN’s NG tube special interest group published Putting Patient Safety First, their report on Never Events relating to NGT insertion.

HSIB launched its investigation after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. This incident was reported as a Never Event.

The report identified numerous reasons why events like this may be able to occur.

It notes that there are no systemic barriers to preventing feeding into an NG tube that has been accidentally placed in the lung. This is largely because present guidance is based on two potentially unreliable techniques: pH testing strips and x-rays. The complexity of pH testing especially is underestimated but incorrect x-ray interpretation is the commonest cause of a NGT Never Event.

Importantly, the report notes significant variation in how existing safety standards are implemented and continually monitored. If clinical staff carefully and consistently followed the guidance on both pH strips and x-rays, the techniques would be more effective.

Among other things, the report recommends that Health Education England should coordinate the development and publication of a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing. This aligns well with NGSIG’s recommendation in their report to limit NGT placements to expert healthcare professionals who receive ongoing support and assessment.

We wholeheartedly endorse the investigation into the causes of NGT Never Events, and we agree with many of the causes HSIB identify.

Our position about the solution, surmised in NGSIG’s Putting Patient Safety First report, places a greater emphasis on the responsibilities of NHS Trusts than HSIB.

But we both wish to see a nationally agreed ongoing training package for NGT placement with only those deemed competent allowed to place NGTs and to report on their position. We urge those whom the HSIB calls upon to act to do so, for the sake of patients and staff across the nation.

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