In April 2004, an inquest was held into the unexpected death of
an eight-year-old girl in an NHS hospital in England. She had
required intubation and ventilation due to respiratory failure
and was temporarily unable to eat or drink. A nasogastric tube
was passed to administer enterai feed. The position of the tube
was checked with the whoosh test (auscultating the epigastrium
for bubbling as air is injected down the tube) and litmus testing
of the aspirate. The whoosh test was positive while the aspirate
from the tube turned blue litmus paper pink, suggesting gastric
acidity. The tip had in fact punctured the pleura to lie in the
pleural cavity. When enterai feed was administered through the
tube her respiratory function worsened. The whoosh and litmus
paper test were repeated. Again, they appeared to confirm the
positioning of the tube in the stomach. Feeding continued and
the girl died. At post mortem a large quantity of feed was found
in her pleural cavity. Following the inquest, the coroner, under
his statutory powers, issued a notice to the NHS. He sought to
avoid a recurrence and drew attention to hazards in routine clinical
practice.'