A patient at Epsom and St Helier University Hospital had a nasal feeding tube wrongly inserted into their respiratory system in a ‘never event’.

Bosses were told about the never event - so named because it should never happen - at last week's hospital trust board meeting.

The mistake was only noticed when food had already been passed through the tube into the patient's respiratory system, and their distress became obvious, an internal report said.

An x-ray confirmed the tube was in the wrong place. The error, which occurred in May, was reported to the Care Quality Commission and commissioning doctors.

Never events can include operations on the wrong body part, surgical instruments being left inside people and wrongly-administered chemotherapy.

A hospital spokesman said: "We are absolutely committed to providing each and every one of our patients with a high level of care and are deeply sorry that in this case, a vital aspect of the treatment provided fell short of the standard we would expect.

"We take incidents such as these very seriously indeed and, although never events are exceptionally rare, we did not hesitate to take action.

"As a result of our detailed investigations, we have improved a number of our practices around nasogastric tubes.

"This includes changing the types of tubes we use, reviewing the training staff receive and increasing the number of competency assessments staff have to pass before they can undertake this procedure."

The hospital has shared the outcome of the investigation with the patient’s family, and chief executive Daniel Elkeles has personally apologised for the shortcomings.

A nine-point action plan has since been put in place. It will be led by the medicine directorate and monitored by the hospital's serious incident panel.