Neglect was the main factor in the deaths of two people at Cumbria's hospitals, a coroner has concluded.

Michael Parke, of Cockermouth and Amanda Coulthard, of Penrith both died from aspiration pneumonia after nasogastric tubes were incorrectly inserted into their lungs - and feeding commenced.

Mr Parke died at the West Cumberland Hospital in Whitehaven on December 6, 2012. Mrs Coulthard died at Carlisle's Cumberland Infirmary on April 26, 2015.

At an inquest into their deaths, which concluded today, chief coroner David Roberts said that there was neglect on behalf of both nurses and management staff at the North Cumbria University Hospitals NHS Trust, which runs both sites.

Mr Roberts said that Mr Parke's death was due to systematic neglect.

He said: "Misplaced nasogastric tubes are a never event. They have been the subject of National Patient Alerts and this trust has suffered one never event before the events with which I am now concerned.

"It is not open to the trust to say that this was a matter that it was unaware of and that accordingly they could not take steps to avoid it.

"The misplacement of nasogastric tubes should have been a trust priority. It was not.

"Directors and managers were so distracted by the potential merger and acquisition by Northumbria that the day-to-day governance fell by the way side - they were asleep at the wheel."

However Mr Roberts said that while Mrs Coulthard's death was a result of neglect, it was not systematic.

He said: "I did not find the evidence that nurses had read the policy prior to Amanda's death convincing and I note there was no documentary evidence to corroborate that oral evidence.

"Even if they had it is abundantly clear that, despite training, at best only lip service was being paid to the policy in place.

"So far as I could ascertain the trust had no means of ensuring that the policy was being complied with on a day-to-day basis.

"There were failings by the senior nurse in charge who should have been leading and acting as an example to other staff members.

"However, on the evidence before me, given the improvement made following Michael's death, I find that there is no systematic failing sufficient to justify a conclusion which incorporates system neglect within it."

Coroner lists points for trust action

There have been three inquests in just seven years as a result of misplaced nasogastric tubes at North Cumbria Hospitals.

And coroner David Roberts highighted his concerns about the cases as he delivered his verdict.

He said: "On the facts of these three cases, the deaths were avoidable. Common themes."

These were, he said:

  • Staff not being aware of the policy
  • Staff not reading the policy
  • Staff not applying the policy
  • Staff not following good practice
  • The trust not ensuring compliance nor rolling out training to all who needed it
  • Lack of checks and audits to establish competence and adherence to policy
  • Failure of the trust to learn from the first death
  • Lack of corporate memory (the issue of NGTs was not on the risk register)
  • The trust not fully implementing the 2011 NPSA alert for over two years and only as a result of the second death
  • Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death
  • The trust policy growing in size from 20 to 36 pages in seven years, making it difficult for busy practitioners to absorb (there are some 200 policies in the trust)
  • The current policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.

Mr Roberts said he would be writing to North Cumbria University Hospitals NHS Trust. He also outlined a series of steps that should now be taken These are:

  • To consider an amplified "summary and aim" at the beginning of the policy to drive him the main points
  • To identify areas where statutory or mandatory training is required
  • To consider the implementation of an online system of statutory mandatory training with a central recording system
  • To take strps to ensure that good and compliant practice is actually taking place on the wards
  • To correct cross referencing errors in the policy.

Mr Roberts told the inquest that he would be writing to both the Secretary of State and NHS England, adding that steps should be taken to ensure that:

  • Research is undertaken to identify a superior method of ensuring correct nasogastric tube placement
  • The issues identified above are addressed nationally - there is evidence set out in the NHS Improvement Resource Set 'Initial Placement of NGTs' July 2016 that demonstrates that the themes set out above are being replicated across other trusts
  • The 2011 alert is properly implemented nationally - the evidence before me was that it has not been

Following the conclusion of the inquest, Stephen Eames, chief executive at North Cumbria University Hospitals NHS Trust, said action has been taken to prevent further deaths.

“I am deeply sorry about these events and I wish to extend my deepest sympathies to the families and friends of Michael Parke and Amanda Coulthard," he said.

"The trust fully takes on board the conclusions of HM Senior Coroner Roberts.

"Patient safety remains of paramount importance to the trust and we expect high standards of patient care which were not met for Michael or Amanda; we sincerely apologise for this.

“As a direct result of the incidents, I would like to reassure the public that we have taken action in order to ensure this does not happen again.

"We will now carefully consider all of the evidence heard at the inquest and the coroner’s conclusions to ensure any further actions are taken as quickly as possible."