Recurring concern
Unsafe management of Ryles and nasogastric tubes
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Request correctionFirst reported 14 Oct 2013•Latest report 9 Feb 2026
What this concern includes
Includes failures of controls specifically dedicated to safe Ryles or nasogastric tube management, including policies and guidance, staff competence, insertion, position verification and repeat checks, authorisation before feeding, ongoing monitoring, timely replacement or escalation, and associated records where they support safe tube care.
Not included
- Excludes generic clinical training, documentation or escalation deficiencies that are not specifically tied to Ryles or nasogastric tube management.
- Excludes enteral feeding, aspiration or gastrointestinal treatment failures where no Ryles or nasogastric tube control is deficient.
- Excludes unrelated vascular, endotracheal or other clinical-tube processes unless the assertion explicitly concerns Ryles or nasogastric tubes.
- Excludes failures limited to the quality of a serious-incident review when the tube-management process itself is not deficient.
- Reports
- 20
- Individual concerns
- 41
- Date range
- 2013–2026
- Stated actions
- 34
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised2
Inadequate evaluation and feedback before wholesale replacement of drainage tubes
Lack of recognition of the need to aspirate the tube
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
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Action
Use the new equipment-evaluation proforma during initial trials to collect user feedback, with assistance from the Specialist Nurse.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Write to UK nasogastric tube manufacturers about ENFit connector risks and request risk-assessment updates and, where applicable, corrective action, revised instructions and staff training.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Contact BAPEN and NNNG to raise awareness of the nasogastric tube safety issue.
Stated by Medicines and Healthcare products Regulatory Agency
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Action
Review and update the LocSSIP for nasogastric and orogastric tube insertion to include troubleshooting guidance on tube aspiration.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Provide nasogastric and orogastric tube aspiration troubleshooting guidance in nursing and medical clinical guidelines.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Update e-learning for nasogastric and orogastric tube insertion and management to include aspiration troubleshooting, competency assessment and self-assessment.
Stated by University Hospitals of North Midlands NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Concerns about hospital tube evaluation, clinical response, and root-cause-analysis training are addressed by a separate NHS England and Improvement response.
Stated by Medicines and Healthcare products Regulatory Agency
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Concerns raised1
Failure to record severe adverse reactions to Naso-Gastric tube insertion
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to correctly place nasogastric tubes
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Amend the nasogastric tube insertion policy to require alternative-feeding review and renewed risk discussions after repeated failed or misplaced insertions.
Stated by South Warwickshire University NHS Foundation Trust -
Action
Explore sourcing an e-learning nasogastric tube refresher module with the learning and development team.
Stated by South Warwickshire University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The nasogastric tube procedure was clinically appropriate, with pneumothorax recognised as a small inherent risk.
Stated by South Warwickshire University NHS Foundation Trust
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Position
Staff training was not a factor in the events because the staff involved were competent and followed current policy.
Stated by South Warwickshire University NHS Foundation Trust -
Position
No further action is proposed regarding staff competency because both practitioners were trained, competent and followed current policy.
Stated by South Warwickshire University NHS Foundation Trust
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Concerns raised1
Repeated distressing nasogastric tube insertion attempts with limited evidence of benefit
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Medical treatment decisions fall outside the Council’s responsibility, so it cannot comment on the individual’s hospital treatment.
Stated by Stockport Borough Council
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Position
The local NHS is expected to reflect on the LeDeR findings and address identified local failings in care.
Stated by Helen Whatley MP
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Concerns raised3
Lack of clear guidance for nasogastric tube practice in the ITU setting
Failure to perform PH testing after nasogastric tube insertion
Failure to follow the nasogastric tube insertion checklist
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to roll out training to all staff who need it
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The principal patient-safety problem is inconsistent implementation, rather than unavailable guidance or ineffective current placement checks.
Stated by Department of Health and Social Care
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Concerns raised8
Failure of staff to apply the nasogastric tube policy
Failure of staff to follow good practice for nasogastric tube use
Failure of staff to read the nasogastric tube policy
Lack of staff awareness of the nasogastric tube policy
Failure to maintain accurate cross-references in the nasogastric tube policy
Nasogastric tube policy becoming difficult for practitioners to absorb
Failure to fully implement the 2011 NPSA Alert on nasogastric tubes
Lack of ward-level systems to ensure compliance with the nasogastric tube policy
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Include delivery-plan progress and compliance with the updated Nasogastric Tube Policy in the 2017/18 Internal Audit Plan for independent Board assurance.
Stated by North Cumbria Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The principal patient-safety problem is inconsistent implementation, rather than unavailable guidance or ineffective current placement checks.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to check whether staff are up to date in training for carrying out procedures
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Strengthen nasogastric-tube competence training through designated trainers and assessors, structured competency stages, verified records and monthly compliance reporting.
Stated by Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Senior Ward Sisters are responsible for maintaining local staff training records, supported by monthly competence-compliance reports as a fallback.
Stated by Mid and South Essex NHS Foundation Trust
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Position
The Trust considers its training, compliance reporting and locally held records sufficient to mitigate the risk of a similar incident.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Lack of skill and training in passing NG tubes
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Inadequate recording of nasogastric tube placement
Feeding via nasogastric tube before completion of full checks
Failure to record nasogastric tube feeding authorisation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026