MHRA tells UK providers to stop using NGPod tube-placement devices

What happened

The UK Medicines and Healthcare products Regulatory Agency told healthcare providers on August 24 to stop using all NGPod handheld devices and sensors, quarantine remaining stock and dispose of the equipment.

The system measures pH to help clinicians assess the placement of a nasogastric tube, which passes through the nose toward the stomach to deliver nutrition, fluids or medication. A reading below pH 5.5 produces a green result indicating contact with acidic fluid. The regulator emphasized, however, that the system does not determine the tube’s anatomical position and cannot independently confirm that it is in the stomach.

The immediate withdrawal follows the manufacturer’s cessation of trading in the UK on July 20. According to the MHRA, the company can no longer provide the oversight, maintenance and support needed for continued use. Distributors were also instructed to cease supply and notify customers who received the affected devices.

Two incidents preceded the withdrawal

The end of manufacturer support was not itself caused by a newly identified safety defect. It followed an earlier Field Safety Corrective Action prompted by two adverse-incident reports received in January 2026.

In both reports, an NGPod device produced a green result after detecting pH below 5.5, suggesting that the tube had reached acidic fluid. The tube was subsequently found in the lung rather than the stomach. One incident had a fatal outcome.

The MHRA said multiple factors were thought to have contributed to that death and did not establish the device result as the cause. It nevertheless said a contribution from the result to the clinical decision pathway could not be ruled out.

Before the manufacturer ceased trading, its instructions for use were updated to identify situations in which acidic respiratory secretions could produce a misleading result. These included significant aspiration of gastric contents and circumstances where clinical assessment indicates that radiographic confirmation is required. The revised instructions also clarified that NGPod alone does not confirm anatomical placement.

Why placement confirmation matters

Feeding, fluid or medication delivered through a tube positioned in the respiratory tract can cause severe injury. NHS England’s enduring safety standards therefore treat confirmation of initial nasogastric-tube placement as a safety-critical process.

Those standards recognize pH within the accepted safe range or an appropriately interpreted X-ray as the acceptable confirmation methods. They reject informal checks such as listening for injected air, looking at the aspirate or relying on the absence of respiratory distress. Equipment used for aspirate testing must be conformity-marked and specifically intended to test human gastric aspirate.

The NGPod alert does not withdraw pH testing as a general placement method. It applies to the NGPod handheld reader and sensor and directs organizations to use alternative suitable pH-testing products under national and local procedures. Providers were also told to review alternative-device stocks to protect continuity of care.

What remains uncertain

The MHRA notice documents two reported false-reassuring results, but it does not provide a denominator showing how many devices, procedures or patients were exposed. It therefore cannot establish an incident rate or quantify the system’s overall failure probability.

Nor does the alert conclude that every green result was unreliable. The regulatory concern combines the earlier incidents, the limits of pH as a proxy for anatomical location and the manufacturer’s inability to support the product after ceasing operations.

The practical regulatory conclusion is narrower: UK providers should no longer use the NGPod system, and a device reading must never be interpreted beyond its intended role. The withdrawal reinforces the need for trained staff, validated equipment and escalation to radiographic confirmation when established placement criteria are not met.