Inspectors rule hospitals have made vital improvements following high-profile patient deaths

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Rod Harpin, medical director
Rod Harpin, medical director

Inspectors have ruled that north Cumbria's hospitals have made crucial improvements following the high-profile deaths of two patients.

However they also said there is still more that can be done.

Michael Parke, from Cockermouth, died at the West Cumberland Hospital in Whitehaven on December 6, 2012, and Amanda Coulthard, from Penrith, died at Carlisle’s Cumberland Infirmary on April 26, 2015.

Both deaths were a result of aspiration pneumonia - after nasogastric tubes were wrongly inserted into their lungs, and feeding commenced.

Cumbrian coroner David Roberts found that there was neglect on behalf of nurses and management staff at the North Cumbria University Hospitals NHS Trust, which runs the hospitals.

It was also highlighted that these were not the first such incidents at the trust, with the first taking place in 2008.

Following the inquest, he wrote to local and national NHS bosses, asking for assurances that lessons have been learnt.

National watchdog the Care Quality Commission (CQC) has since carried out a focused inspection at the trust.

After visiting the hospitals in July this year, inspectors have today published their findings - confirming that the insertion and management of nasogastric tubes is now ‘safe, effective and well-led’.

However they also identified some areas where further work is needed.

The inspection took place across medical, surgical, paediatric and intensive care wards at the Cumberland Infirmary and West Cumberland Hospital.

The team also checked the trust's progress against the delivery of an action plan, drawn up in response to the coroner’s concerns.

The inspection found that:

  • Staff assessed the needs of patients and delivered care in line with existing policies. Procedures were also compliant with national best practice guidance.
  • There had been no serious incidents regarding nasogastric tubes since April 2015.
  • Clinical staff involved in the insertion of a nasogastric tubes were now required to complete mandatory training.
  • Clear processes were in place to manage the progress of the action plan developed in response to the coroner’s concerns.

It also highlighted improvements in the reporting of incidents or near- misses, and said staff were fully supported to attend meetings where feedback and learning was encouraged.

However it also identified areas that still need addressing. They are:

  • Ensure the proposed new nasogastric insertion record for patient care plans is more detailed and contains more guidance as well as a summary of the reasons why the patient has one.
  • Develop a specific policy around the use of nasogastric tubes for pregnant women.

Dr Rod Harpin, the trust's medical director , said: “We have rightfully spent a lot of time reflecting on the learning for the whole organisation following the deaths of two of our patients in order to ensure this does not happen again.

“We are pleased that the CQC has recognised the amount of work the trust has undertaken in order to improve our nasogastric care management, processes and policies.

"However, the work does not stop here and all of our staff are committed to continuing to make further improvements in safety for our patients.”

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