Unintentional perforation of oesophagus in neonates from invasive procedures

Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.

A review of similar cases identified where oesophageal perforation occurred in neonates following intubation, insertion of a gastric tube, or both. Many incidents involved premature neonates and described complexity completing the procedures, often involving more than one attempt at passing the tube(s).

The team liaised with the British Association of Perinatal Medicine who have included a recommendation in their new ‘Managing the Difficult Airway in the Neonate’ framework. This publication supports organisations and clinical staff to respond to the ‘difficult neonatal airway’ in a stepwise fashion and includes advice that the algorithm should be activated after two failed attempts.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.

A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.