A recent coroner’s report in the UK concluded that a healthy patient died as a result of unrecognised oesophageal intubation. This did not seem to be the result of misinterpretation of a flat end-tidal carbon dioxide trace, but an apparent omission to check the capnograph after intubation and to perform clinical checks of tracheal tube position. This podcast accompanies a new editorial from Pandit, Young and Davies which highlights the main lessons that can be learned from this tragic event. Joining Professor Pandit we are delighted to have with us Professors Laura Duggan and Andrew Smith. The tread from Tanya Selak to accompany the podcast can also be found here.