Hospital feeding tube put in the wrong place
- Credit: NNUH
A tube which was supposed to be put into a patient's stomach was instead put into the windpipe.
It happened last month at the Norfolk and Norwich University Hospital (NNUH), and was so serious it was deemed a never event, a situation which should never happen.
The incident involved a nasogastric tube, which is inserted via the nose and used for feeding or giving medication.
But if the insertion is not done correctly rather than going into the stomach, the end of the tube can go into the windpipe and up in or between the lungs.
Misplacing the tube can be fatal and the NHS put out an alert over these incidents in 2016.
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A spokesman for the Norfolk and Norwich University Hospital said: 'We regret the occurrence of any never event and are absolutely committed to ensuring our patients receive the highest quality care.
'We investigate all incidents in order to identify ways to improve and cases are reviewed by a multi-disciplinary team involving doctors, nurses and other professional staff.
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'We report all our clinical incidents to the NHS National Reporting and Learning Service (NRLS), so that any common themes or issues can be identified and lessons shared.
'All identified learnings from these incidents will be shared appropriately within the trust as part of our drive for continuous improvement and in order to ensure the best care and experience for our patients.'