A DELAY in inserting a nasogastric tube contributed to the death of a well-known Clitheroe figure, according to a coroner.

Now, following an inquest into the death of 68-year-old Gillian McKinlay, Dr James Adeley, senior coroner for Lancashire and Blackburn with Darwen, is calling on the East Lancashire Hospitals NHS Trust to take action to prevent future deaths.

Mrs McKinlay, the wife of retired GP Dr David McKinlay, died at the Royal Blackburn Hospital on April 23, 2018.

The couple moved to Clitheroe from the North-East and played an active part in the community.

She was a guide leader, a governor of Pendle Junior School and parish church counsellor, and also served as wardrobe mistress for Clitheroe Amateur Operatic and Dramatic Society.

She was admitted to the hospital’s accident and emergency department and the provisional diagnosis was of a small bowel obstruction.

Both the A and E and surgical registrars called for an NG tube to be inserted to decompress the bowel.

However, the inquest heard that the tube was not sited prior to Mrs McKinlay’s death four hours later.

The coroner said that despite indications that there should have been a significant review of her condition within the two-and-a-half hours before she arrested there was no evidence that any such review took place.

The cause of death was given as ” incarcerated femoral hernia and aspirate pneumonia, contributed to by failing to site an NG tube and inadequate clinical review and treatment by A and E department staff”.

Dr Adeley has raised four matters of concern with the NHS Trust and Care Quality Commission .

The first states: “For patients remaining for a considerable period of time in the A and E Department there is no clear indication or understanding as to who is responsible for the overall patient’s clinical care.”

The coroner also highlights the fact that Mrs McKinlay’s condition was not reviewed, even after the NG tube was unable to be inserted.

The Trust held a serious incident review following Mrs McKinlay’s death but the coroner expressed concern about the adequacy of the investigation and the steps taken as a result.

He wrote: “The Trust’s response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that ‘training on insertion should shorten time taken to decompress’ is inadequate.”

In response Mr Jawad Husain, executive medical director for East Lancashire Hospitals NHS Trust, gave his condolences to Mrs McKinlay's family and pledged that the Trust would learn from its mistake.

He said: “I would firstly like to offer my sincere condolences to Mrs McKinlay’s family. Our vision is to provide Safe, Personal and Effective care for all of our patients. However, the standard of treatment given to Mrs McKinlay fell way below our extremely high expectations and for that we are truly sorry.

“We welcome any opportunity to learn from our mistakes so that we can improve our services and avoid similar errors in the future.”

The Trust and CQC have been given until May 28 to respond to the coroner’s report.