NHS trust branded ‘shambolic’ over two patient deaths when feeding tubes were inserted into their lungs
Inquests heard the blunder caused pneumonia in Michael Parke and Amanda Coulthard
AN NHS trust was branded “shambolic” over the deaths of two patients who had feeding tubes inserted into their lungs instead of their stomachs.
Inquests heard the same blunder caused pneumonia in Michael Parke, 40, at West Cumberland Hospital in Whitehaven, and Amanda Coulthard, 57, at Cumberland Infirmary in Carlisle.
Recording narrative verdicts, Cumbria chief coroner David Roberts said it should have been a “never event”.
He fumed: “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, day-to-day governance fell by the way side — they were asleep at the wheel.”
North Cumbria University Hospitals Trust said it was “deeply sorry” over the 2012 and 2016 deaths.
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Stephen Eames, chief executive of North Cumbria University Hospitals Trust, said: “I wish to extend my deepest sympathies to the families and friends of Michael Parke and Amanda Coulthard.
“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.