We’ve spent more than 15 years writing guidelines to stop feeding tubes going into the wrong place. It still happens.

Rarely because anyone was careless — often the opposite: the team followed every step.

The problem is that our two main safety checks — a pH test and a chest X-ray — can each be wrong. The national investigation into nasogastric tube placement found that incorrect X-ray interpretation is the single most common cause of these incidents.

A safety net with a known blind spot isn’t really a safety net.

This is the start of a short series on why NG tube safety needs a rethink — because the harm here reaches well beyond the rare “Never Event” that makes the headlines.