Training on the insertion of feeding tubes was not made mandatory at north Cumbrian hospitals – despite an earlier death of a man.

Speaking at the inquest into the deaths of Amanda Coulthard and Michael Parke, Christine Platton – who held the position of director of nursing at North Cumbria University Hospitals NHS Trust in 2011 – told coroner David Roberts that training was offered prior to the death of Mr Parke, from Cockermouth, at the Whitehaven hospital in 2012.

At the inquest in Kendal, Mr Roberts was told that Mrs Coulthard and Mr Parke had died after nasogastric tubes were incorrectly inserted into one of their lungs, rather than their stomach, and that feeding had begun before the error was identified.

Mrs Platton said that the trust had experienced “difficulties” in encouraging doctors and nursing staff to complete the nasogastric tube course at both Carlisle’s Cumberland Infirmary and the West Cumberland Hospital.

Questioning Mrs Platton, Matthew Holdcroft, counsel to the inquest, asked: “Was it considered to be mandatory?”

Mrs Platton, who now holds the position of associate director of nursing development, said: “I can’t answer that. Did we look at making it mandatory? We said ‘yes we can influence that’ [the number of staff taking up training] but at that time we did not consider it to be mandatory.”

Ashley Pratt, representing Mr Parke’s family, asked why the training was not made mandatory following the death of Ronald Smith at the Cumberland Infirmary in 2008 – a “never event”.

Mrs Platton said: “If there’s learning to be taken from a ‘never event’ then looking back in hindsight, then yes, it should have been.”

Giving evidence, Mrs Platton said that she raised immediate concerns about being appointed lead director when a National Patient Safety Alert regarding the insertion of nasogastric tubes was issued in March 2011.

Mrs Platton explained that she believed Mike Walker, the

trust’s then medical director, should undertake the role. Mr Walker previously said that at the time he thought the role was best suited to Mrs Platton.

Mrs Platton admitted that she did not approach the chief executive – which switched from Carole Heatly to Neil Goodwin in June 2011 – with her concerns.

She said that in hindsight she should have gone over Mr Walker’s head and spoken to the chief executive.

She was asked by Mr Pratt what had stopped her approaching the chief executive. He asked her whether it had been a personality issue.

Mrs Platton said: “No, there was no personality reasons at all. Clearly at the time it was different to when Ann Farrar [who took on the role of interim chief executive in September 2012] came in, when there was much more construction and we reported in a different way.”

At the end of her evidence, Mrs Platton asked Mr Roberts if she could address both families.

She said: “Mr and Mrs Parke, I’ve not had the opportunity until now to speak to you. I want to offer my apologies for the short failings. I sincerely want to apologise for the distress since Michael’s death. I also want to extend that to Mrs Coulthard’s family.”

Mrs Coulthard, from Penrith, died at the Cumberland Infirmary in 2015.