A hospital made a potential deadly error after it inserted a tube used for feeding into the wrong part of a body.

New data from the NHS showed that West Hertfordshire Hospitals Trust recorded one major incident last year when a naso or orogastic tube was misplaced into the lung of a patient.

This was recorded as a ‘never event’, which are serious, largely preventable patient safety incidents that should not occur at any time.

Although misplacing the tube was the only mistake the trust made between April and the end of November in 2019, making such a mistake could result in a patient losing their life.

According to the NHS the tube is used to provide fluids, medication or nutrition, but there is a risk that once inserted it may be misplaced into the lungs.

If this is not detected before the tube is used, it can result in serious harm or death.

It is not clear which of the three hospitals in Watford, St Albans and Hemel Hempstead that the incident occurred.

West Hertfordshire Hospitals Trust chief medical officer Mike van der Watt said: “We are very sorry that this incident occurred. We followed trust protocol for this procedure but due to an unfortunate reporting error we didn’t correctly assess that the nasogastric tube was positioned in the lung.

"Fortunately a swift response by staff ensured that the patient did not experience significant harm or distress. The patient and their family were fully briefed on what happened and we have provided further training to the staff involved.”

Nationally, there were some 302 incidents in hospitals that were so serious they were classed as a ‘never event’ between April and November last year.

The most common accident recorded was surgery being performed on the wrong person or the wrong part of a person’s body – 151 incidents had been recorded in just seven months.

The NHS also recorded 29 serious incidents throughout the same time period but did not meet the definition of a ‘never event’.

In the report published by the NHS, it said: “The concept of Never Events is not about apportioning blame to organisations when these incidents occur but rather to learn from what happened.

“This is why, following consultation, in the revised Never Events policy and framework – published January 2018 we removed the option for commissioners to impose financial sanctions when Never Events were reported.

“Identifying and addressing the reasons behind this can potentially improve safety in ways that extend far beyond the department where the Never Event occurred, or the type of procedure involved.”