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."

Stephen Eames, chief executive at North Cumbria University Hospitals NHS Trust, said: “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.

"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.”