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.'