Crucial training at a Black Country care home where a pensioner died after a feeding tube was inserted into his lung was “almost non-existent”, an inquest heard.
Ronald Kemble, aged 81, died at Russells Hall Hospital on December 1, 2007, just days after being transferred from the 40-bed Warrens Hall Nursing Home, in Tividale, Oldbury.
The inquest into his death was opened at Smethwick Council House with home office pathologist Dr Kenneth Shorrocks giving Black Country coroner Robin Balmain the results of a post-mortem examination.
Dr Shorrocks found Mr Kemble’s right lung weighed nearly five times more than it should, at 1195 grammes. It was compacted with “material,” he said. Mr Kemble’s left lung was also compacted, at almost three times its expected weight.
“It appears a feeding tube didn’t go down into his stomach, it went down his air passages and into his right lung,” said Dr Shorrocks. “This was a significant event that caused his death at that time.”
The home was run by Associated Nursing Services (ANS) before Bupa took control at the start of 2007.
Vivian Parsons, a senior nurse at the home between December 2002 and November 2008, told the hearing she couldn’t remember being given essential nursing updates during ANS’s time in charge. One update, in 2005, covered procedures for checking feeding tubes were inserted correctly.
She described training at the home under ANS as “almost non-existent” and said there had been many other problems, including a high staff turnover.
However, many problems at the home were addressed “almost immediately” after Bupa’s takeover, added Mrs Parsons.
Mr Kemble had been in Russells Hall Hospital just before moving to the home near the end of November, his 43-year-old daughter, Joanne Yale, told the court.
He was in hospital having suffered a severe stroke at his own home, in Halesowen’s Acorn Road, in mid-October. The stroke meant he couldn’t swallow properly and needed a feeding tube.
The case continues.