A top hospital boss has admitted that lessons were not learned following the death of a patient in Carlisle.

Giving evidence at the inquest into the deaths of Amanda Coulthard and Michael Parke, board members at North Cumbria Hospitals NHS Trust admitted that the death of 81-year-old Ronald Smith was not discussed when a National Patient Safety Alert (NPSA) was issued in 2011.

It was issued regarding the insertion of nasogastric feeding tubes.

Mike Walker and Neil Goodwin - the trust’s former interim chief executive from June 2011 to July 2012 – said that Mr Smith’s death had not been raised by the hospital hierarchy.

Mr Smith died following the incorrect insertion of a nasogastric tube at Carlisle’s Cumberland Infirmary.

The inquest has already been told that the incorrect insertion of tubes caused the death of both Mrs Coulthard at the Cumberland Infirmary in 2015 and Mr Parke at the West Cumberland Hospital in 2012.

Mr Walker - who issued an apologised to Mr Parke's parents - said he was unaware that he had been tasked with finding a clinical lead for the implementation of a new policy on the insertion of nasogastric tubes.

He told coroner David Roberts that he had only received an email detailing the alert a month after it had been issued, when it was forwarded on to him.

Giving evidence, Mr Walker – who held the position of medical director at the trust until 2013 - told coroner David Roberts that he believed the NPSA was the responsibility of director of nursing, Christine Platton, rather than himself.

Mr Roberts was told by Matthew Holdcroft, counsel to the inquest, that Mr Walker had not responded to emails in which he was asked to appoint a clinical lead. Mr Walker also admitted - in hindsight - that Christine Platton should not have been the executive lead.

The alert outlined the policy that should be taken to ensure that a tube has been fitted correctly, adding that only a doctor should authorise an x-ray to determine the tube’s location.

Mr Holdcroft asked Mr Walker: “As a matter of common sense, does it seem that the apparent clinical lead should be a doctor rather than a nurse?” to which he replied: “Yes.”

Mr Holdcroft also told the coroner that a diagram regarding the placement of NG tubes had been included in the alert. Mr Walker said: “That’s correct. The diagram was not included before the death of Michael Parke.”

Mr Holdcroft also drew the coroner’s attention to a chain of emails between senior hospital staff and pointed out that a revised draft policy was not circulated until February 2012.

He told Mr Walker: “You’ve had six months, you’ve given yourself an extra two months after that. Why hasn’t this been moved to the top of the list?”

In his final questions to Mr Walker, Mr Holdcroft asked: “Do you agree that the safety alert in the document should not be difficult to implement?” to which Mr Walker agreed.

Mr Holdcroft continued: “It should not take very long at all, should it?” to which Mr Walker also agreed.

He then asked: “Lessons should have been learned by your trust before the tragic death of Michael Parke shouldn’t they?” to which Mr Walker said: “Yes.”

Addressing the time it took to implement the policy with Mr Goodwin, Mr Holdcroft said: “On the face of it this should be a high priority policy?”

During questioning, an emotional Mr Walker also took a moment to address Mr Parke’s parents, Norman and Helen. He said: “This has been difficult for me. I am truly sorry. I should have had the opportunity to say something before now – I am truly sorry.”

Mr Walker added that he has worked in west Cumbria for the past 25 years. He continued: “I care, we all truly care… Sometimes we fall short of what we want to achieve.”

Norman Parke responded to Mr Walker, saying that he understood where he was coming from.