Patient safety: unrecognised oesophageal intubation

Patient safety lies at the heart of healthcare. It is one of the most significant concerns across the NHS and independent sector and is a key priority for the College. A key factor to driving forward patient safety is maximising the things that go right and minimising the things that go wrong. Learning from mistakes by addressing systemic factors in order to prevent future harm is essential to improving patient safety.

Unrecognised oesophageal intubation

The College has received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. The College endorses the Preventing unrecognised oesophageal intubation consensus guidelines produced by the Project for Universal Management of Airways.

Coroners Report

Here you can find three coroners reports on unrecognised oesophageal intubation:

Coroners report September 2021 - an updated response from the Association, College and DAS is available here

Coroners report January 2018

Coroners report November 2017

No trace = wrong place

We previously launched the popular No Trace = Wrong Place campaign to highlight the correct use of capnography to prevent undetected oesophageal intubation.

All clinicians involved in airway management should watch the College and DAS video on capnography. We ask that they always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.

This short video is only seven minutes long - perfect to watch on your coffee break:


Video resources

We have a collection of videos that are highly informative and worth sharing with your colleagues. 

Watch videos


Read the Bulletin articles 

Multidisciplinary team training

Multidisciplinary team training has an important role to play in rehearsing emergency drills, embedding non-technical skills in practice and allowing teams to learn how to function well as a whole within a flattened hierarchy. We have developed the following resources to support departments to deliver team training:

We recognise that time is the biggest barrier to team training and have thus developed three short, flash card simulations to enable this to be delivered as a talk-through scenario in 5 minutes. We ask all departments to use these flash cards on the subject of unrecognised oesophageal intubation and to provide us with feedback.

The flashcards can be downloaded here

Tea trolley training
Dr Fiona Kelly using tea trolley resources

SALG recommendation for capnography positioning and appearance on monitoring screens

SALG has released a recommendation on capnography positioning and appearance on monitoring screens with the aim of preventing unrecognised oesophageal intubation. The statement can be read on SALG's website SALG Statement on Waveform Capnography

If you have any queries about our patient safety workstream, please contact us