A 12-year-old female with autism spectrum disorder and severe behavioral regression was admitted with profound malnutrition and worsening neuropsychiatric symptoms.
Since early 2024, she experienced progressive functional decline, including loss of speech, sensory aversion, psychotic-like episodes with hallucinations, aggression, and complete refusal of oral intake. Her weight dropped from 60lbs to 40lbs over several months. Despite efforts to obtain outpatient psychiatric care, access was delayed, and her clinical condition continued to deteriorate, leading to inpatient evaluation for nutritional and neurologic workup.
On 12/11, during a sedated procedure for lumbar puncture and brain MRI, an 8 Fr nasogastric tube with a bridle was placed by a resident under the supervision of a pediatric gastroenterologist. The bridle was secured per standard technique, and the procedure note states that the patient tolerated it well with no complications. However, the medical record does not contain any documentation of post-placement X-ray confirmation of NG tube position prior to securing it with the bridle or initiating feeds.
A screenshot of the "procedure note" is attached.
The following day, the patient acutely decompensated with hypotension, hypoxia, and tachycardia. A stat chest X-ray revealed that the NG tube had entered the airway, followed the left main bronchus, and perforated into the left pleural space. (SCREENSHOT OF XR RESULT ATTACHED).
This resulted in a large pleural effusion and left lower lobe airspace disease and was identified as the likely cause of her clinical decline. Pediatric surgery placed a left chest tube and reinserted the NG tube, this time with radiographic confirmation. Despite initial stabilization, the patient later developed a loculated empyema, confirmed by CT on 12/24, requiring reinsertion of a chest tube on 12/25. She also received intrapleural Alteplase (12/18–12/20) during her earlier course for persistent effusion. Chest tube was removed on 12/29. Serial CXRs showed eventually stable/improving. Patient DC on 12/31.
Patient will require extended pulmonology follow-up and has ongoing pain/episodic difficulty breathing.
We have concerns about the safety and appropriateness of bridle-secured NG tube placement without radiographic confirmation, especially in a neurologically vulnerable, malnourished child with altered mental status.
An opinion is requested to assess whether the procedure met the standard of care, whether supervision and verification protocols were properly followed.
Questions and clarifications are welcome.
Files:
Q: Was the NGT placement confirmed by checking pH, or pushing a syringe of air into NGT then hearing a gush?
A: The attached note from the resident appears to be the only documentation of the NGT placement. So, it does not appear so.
Do you believe there might have been medical error?
Re: Expert Medical Review — NG Tube Placement Complication Patient: 12-year-old female with autism spectrum disorder and severe behavioral regression I have reviewed the case summary concerning the above-referenced patient, who suffered a significant complication following nasogastric (NG) tube placement on December 11, 2024. Based on the information provided, it is my opinion as a pediatric gastroenterologist that a medical error likely occurred in this case. Below, I outline my reasoning, as well as important questions that should be answered to fully evaluate the circumstances. The standard of care for NG tube placement—particularly in pediatric patients, and even more so in patients with altered mental status, developmental delay, or malnutrition—requires radiographic confirmation of correct tube position before feeding or medication administration. Additionally, securing a tube with a bridle should only be done after confirmation that the tube is properly placed, because a bridle makes repositioning or removal more complex and can delay response if malposition is discovered later. Although there is no formal training for bridle placement, it does need to be done by someone with sufficient experience. Based on the information provided, the worrisome features of this case include: There is no documented radiographic confirmation of the NG tube position after placement and the tube was secured with a bridle before confirmation of gastric placement. It would be important to know if feeds were initiated, resulting in the tube delivering contents into the airway and pleural space. In my opinion, using the information provided, the failure to confirm tube position with imaging prior to use represents a deviation from the standard of care. However, it is important to gather additional details to fully understand whether the clinicians believed the tube was correctly placed, or if other factors contributed to the decision-making process. What verification methods were used by the clinicians, for example, did the team perform bedside assessments (e.g., auscultation, aspiration for gastric contents, pH testing) and where did they document these findings? If bedside checks were done, what results led the team to conclude the tube was in the stomach? Does the hospital have an established protocol requiring radiographic confirmation before securing a bridle or starting feeds? Were the clinicians aware of and trained on these protocols? What level of oversight did the supervising pediatric gastroenterologist provide during and after placement? Did the attending physician personally verify tube placement? When were feeds or medications first administered through the tube relative to its placement? Did the patient show any immediate signs of distress during initial feeding that might have raised suspicion? Did any unique patient factors influence the decision to secure the tube without X-ray? Was there urgency or logistical limitation preventing immediate imaging? How was the decision made to place a nasogastric tube of that size? Given the patients’ altered mental status, how long was the patient incapacitated after the procedure, and therefore could not express distress or show physical signs of discomfort? Based on the available records, the failure to confirm NG tube placement radiographically before securing the bridle and initiating feeds constitutes a deviation from the standard of care and likely contributed directly to the patient’s severe complications. I would be interested in reviewing the full medical record and the actual images obtained. Nevertheless, it is critical to clarify the above questions to determine whether the clinicians had any documented basis to believe the tube was correctly positioned, or whether systemic, training, or communication factors may have contributed to this outcome. I remain available for further review or testimony as needed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Please refer to the previous statement, further discussion regarding causation would be strengthened by having the full medical record and knowing the answers to the outstanding questions regarding this case.
What makes you a good expert for this case?
I am a board-certified pediatric gastroenterologist with 15 years of clinical experience, including specialized training as an advanced endoscopist. I have personally placed numerous feeding tubes, including nasogastric tubes and have experience with bridle-secured systems, though I am among the fewer practitioners in my field who routinely utilize bridle locks. Additionally, I have served as a medical expert in multiple legal cases for both plaintiffs and defendants, and I am familiar with the standards of care and procedural protocols relevant to enteral tube placement in pediatric patients.
How often do you encounter cases similar to this one in your practice?
Although uncommon, complications due to feeding tubes do occur. As Clinical Director, I have been involved in instituting a feeding tube protocol with verification of location at my current institution.
Do you believe there might have been medical error?
The standard of care is to check placement of NGT before use. If there was no x-ray obtained, then another method (such as checking pH or pushing a syringe of air and hearing the gush (over the stomach) should be performed to confirm placement. If another method was not performed to check placement, then there was a medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Assuming there was no confirmation of NGT placement (using any of the methods above), then the subsequent clinical decompensation was from the NGT/feeds or meds given via NGT. A foreign body (NGT) in the airway alone can cause obstruction, inflammation, perforation, and respiratory distress (even without initiation of feeds). If NGT feeds were given, patient would be clinically worse.
What makes you a good expert for this case?
I would only testify to help the physician, so would do it if there was a method used to check NGT placement (aside from xray). I am a pediatric gastroenterologist who sees many children with failure to thrive so have a lot of experience with feeding tubes and their placement. I was in a deposition in the past where the plaintiff named every doctor who ever saw the patient, rather than naming the specific doctor at fault. The plaintiff's lawyers all agreed to drop me from the case because they knew I wasn't at fault, but also said that if I were to be put on the stand, I have a demeanor such that the jury would side with me.
How often do you encounter cases similar to this one in your practice?
I have seen 2-3 similar cases in recent years.
Want to open a case or submit response?
Comments are accepted only from Pediatric Gastroenterology experts.