The death of a Cumbrian woman who was suffering from lung cancer may have been accelerated by a trainee doctor’s error.

Susan Agnew, 61, passed away in her Whitehaven home on May 19 last year due to a blood clot in the artery to her lungs, caused by her cancer.

A Cockermouth inquest heard that Mrs Agnew’s oesophagus had been torn while she underwent a bronchoscopy – an examination of the lungs – at the Freeman Hospital in Newcastle in December 2015.

Her husband Joseph Agnew said the incident left his wife unable to sleep and with a swollen face and neck.

Treatment was delayed while she recovered from the tear, which occurred when trainee Dr Lay Ping Ong inserted a rigid bronchoscope into her oesophagus instead of her trachea.

Dr Nicholas Shaw, assistant coroner for Cumbria, recorded a narrative verdict, finding the mother-of-two had died of “natural causes which may have been accelerated by a complication of a necessary surgical procedure”.

Dr Sion Barnard, consultant thoracic surgeon at the Freeman Hospital, who was supervising Dr Ong, said the procedure required an “element of faith” as they both couldn’t look down the tube.

He believed the incident was “very rare”, saying “I’ve never seen it before and I doubt I’ll see it again”.

He found the medical cause of death to be pulmonary embolism (a blockage in the artery to the lungs) due to lung cancer, with contributing factors of the perforation to her oesophagus and pneumonia.

Pathologist Dr Susan Davies, who carried out the post mortem, reported that the perforation “may have contributed to the death as it delayed treatment” but it “did not cause the death” which was “likely to have occurred anyway”.

Due to the tear, Mrs Agnew had to be fed through a tube and suffered repeated infections.

Dr Shaw said he would “never know” if without the delay to her treatment it “would have made a difference”, adding her “treatment didn’t get started because of PEG (feeding tube) issues and chest infections” and she was “too poorly to start chemotherapy”. She did receive palliative radiotherapy.

He said: “By the time she was admitted to West Cumberland Hospital in the middle of March, I strongly feel it had advanced to such a stage it was going to be terminal anyway.”

Dr Ong, who had previously carried out the process on 20 occasions, apologised to the family. She said: “I always try to exert as little force as I can. I’m really regretful and really sorry.”

Mr Agnew said his wife, a former Sellafield and Bethany House Care Home cook, was the “rock of the family”, who loved to care for her three grandchildren.