The failure of staff at a BUPA-run care home to use modern nursing practices contributed to the death of an 81-year-old pensioner, a coroner has ruled.
Black Country coroner Robin Balmain returned a narrative verdict into the death of Ronald Kemble, from Halesowen, who died after a feeding tube was wrongly inserted into his lung at Warrens Hall Nursing Home, in Tividale.
He said outdated procedures at the centre were partly to blame.
Mr Balmain heard that the procedures used had been flagged up as unsafe by the National Patients Safety Agency (NPSA) two years earlier.
The home had been run by Associated Nursing Services (ANS) before BUPA took control at the start of 2007.
Former senior nurse Vivian Parsons had told the inquest that she couldn’t remember being given essential nursing updates during ANS’s time in charge. She said most of the problems at the home had been addressed after BUPA’s takeover.
The inquest heard that the mistake with the feeding tube went undetected by care staff for more than four hours.
It was only discovered when Mr Kemble’s daughter Joanne Yale visited and found him collapsed in bed and unable to breathe.
The widower was rushed to Russells Hall Hospital, in Dudley, where he died five days later on December 1, 2007.
Following the fatal incident, a police investigation was launched but no charges were brought against the care home or its staff.
Mr Kemble, a retired manager with Bookers Cash & Carry, in Stirchley, Birmingham, had been admitted to the home after suffering a stroke.
Victoria Blankstone, a medical law solicitor with Irwin Mitchell, representing Mr Kemble’s family, said: “This was a tragic error which could have been avoided.”
Mrs Yale said: “I feel so angry that they let both Dad and me down so badly. They robbed me of the little time that I had left with him.”