A Cumbrian woman’s last six months of life were “hell”, a coroner has been told.

Speaking at the inquest into the death of her sister Amanda Coulthard, Shelley Banks said that the 57-year-old appeared “distraught” when the family visited Carlisle’s Cumberland Infirmary on April 17 last year.

Giving evidence yesterday, nursing expert Irene Waters also told coroner David Roberts that staff at the hospital had not followed best practice when inserting a nasogastric feeding tube or obtaining a pH reading to confirm its position.

In the early hours of April 18 it was discovered that the tube had been inserted into the right lung of Mrs Coulthard, from Penrith, rather than her stomach. She died on April 26, 2015.

Mrs Banks said that she had looked after her sister following the death of Amanda’s husband, Kevin, in 2009, adding that it had hit her quite hard.

She said: “She just relied on me. She loved phone calls from the girls [Her daughters Jordan and Chelcie]. She was just a loving sister and we all miss her.

“We just wish she was here… the last six months of her life were hell. We don’t want anyone to go through that.”

Mrs Waters, who was asked to compile a report into Mrs Coulthard’s death by Cumbria police, raised a number of concerns about the procedures undertaken by nurses Rosemary Murray, Kerry Richardson and Alex Irving when the nasogastric tube was fitted on April 17.

She told the coroner: “When I read the statements [of the three nurses] there were references to activities which had not been documented.”

Mrs Waters also raised a number of concerns about the practice of nurses, including the fact that Rosemary Murray did not witness Alex Irving obtain a pH reading, adding that two nurses should be witness the test for aspirate.

Mrs Waters also raised concerns that a nasogastric tube Kerry Richardson and Rosemary Murray attempted to insert was reused when they encountered difficulties, explaining a new tube should have been used.

She also expressed concern that the nurses had used nearby drinking water as lubricant, rather than obtaining fresh water, which she said did not necessarily have to be sterile.

Matthew Holdcroft, counsel to the inquest, asked Mrs Water whether nurses had been complying with best practice, to which she said: “No.”

Robert Wyn-Jones, representing Kerry Richardson and Alex Irving, asked Mrs Waters if she had any sympathy for nurse Irving in that she had not asked Rosemary Murray to witness the pH reading.

Mrs Waters said: “She was the senior nurse on that shift. She should have known better. If it was the other way round I’d have expected her to be critical of nurse Murray.

“She should be making sure it was done properly.”

The inquest is being held alongside that of 40-year-old Michael Parke from Cockermouth who died at the West Cumberland Hospital on December 6, 2012.

Last week the inquest was told that he too had a nasogastric tube incorrectly inserted into his lung and that feed had been issued before staff realised an error had been made.

The inquests continues.