Later on in that shift the nurse inserted the fine bore NG tube and asked the

evening Senior House Officer (SHO) to order a portable X-ray to check its position

The X-ray was reviewed by the night HDU SHO at 0100 hrs

It was thought the X-ray was a little rotated, but that the position was probably

slightly altered due to the hiatus hernia

Feeding was commenced

The patient's respiratory function deteriorated overnight

When the patient was reviewed on the morning ward round, the X-ray was

reviewed again and the team felt that the tube might be misplaced

The tube was removed and the patient treated for aspiration of feed with bronchial

lavage (which confirmed feed in the bronchi) and adjustment of her antibiotic

regime