THE death of a widow and great-grandmother after a feeding tube was inserted in her lung rather than her stomach was partly the fault of “system neglect” at the hospital, a coroner has ruled.

Margaret Mary Burton, 90, a former shopkeeper, died from lung infections and pneumonia after a nasal feeding tube was inserted into her lung at the University Hospital of North Tees, in Stockton.

At an inquest yesterday, Coroner Michael Sheffield recorded a verdict of accidental death, contributed to by system neglect.

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He said he was satisfied that doctors at the hospital were now properly trained in dealing with X-rays.

Explaining his verdict, he said: “The hospital failed to have a system to check whether the doctors concerned had the appropriate competency.”

The inquest heard that Mrs Burton, a great-grandmother to three, of Park House Residential Home, Stockton, had suffered a stroke and was unable to swallow properly.

A nasal gastric tube was inserted but nurses’ tests caused them to request an Xray to make sure the tube was in the right place. The doctor checking the C-ray, Dr Rajkumar Arasappan, said the tube was fine.

However, nurses again became concerned the following day and requested another Xray.

This time the mistake was spotted, but Mrs Burton died three days later.

Dr Arasappan admitted he had misinterpreted the X-ray at the inquest. He is now working at another hospital.

Mrs Burton’s daughter, Anne Anderson, said: “When I visited my mum the morning after the tube was inserted, I knew something was very wrong because she was babbling incoherently.

“I took her hand and asked her to blink twice if she was in pain and frightened. She blinked twice.

“Although she would possibly never have fully recovered from the stroke, one doctor’s mistake meant my mum suffered a distressing end to her life. Hopefully no one else will ever die in this way again and no other family will have to suffer what we have had to.”

The inquest heard that a national alert had been raised about the insertion of nasal tubes in 2005. Stockton Hospital changed procedures, but since Mrs Burton’s death, every doctor at the hospital now has specific training.