Abstract
A 55-year-old woman developed a postoperative ileus with associated nausea and vomiting following an elective laparotomy. A wide bore nasogastric (NG) tube was inserted for gastric decompression and symptom relief. Aspiration of the tube was unsuccessful and the patient continued to vomit. Imaging to investigate the acute abdomen demonstrated the nasogastric tube to be correctly sited and within pooled gastric contents. Gentle initial attempts were made to unblock the NG but to no avail and therefore it was removed. On inspection it was discovered that the NG tube had no distal perforations to allow drainage, causing failure and increasing the patient’s risk of aspiration. The aim of this report is draw attention to the importance of scrutinising all medical equipment prior to use to prevent avoidable and potentially serious patient harm.