A TRACHEOSTOMY patient died after the “fatally flawed” set up of a machine used to help him breathe had “inevitable and disastrous” consequences.

A three-day inquest at Bradford Coroners’ Court heard Geoffrey Kilbey, 60, of Hillworth Village, Oakworth Road, in Keighley, was admitted to Airedale General Hospital in March 2016 after collapsing.

He was taken into intensive care and had to be sedated and fully ventilated with a tube down his throat. After his oxygen levels initially improved, a tracheostomy was carried out in a bid to wean him off the ventilator using Continuous Positive Airways Pressure (CPAP), where a patient breathes on their own but needs help to keep their airway unobstructed.

Evidence given at the inquest outlined how a nurse mistakenly used the wrong machine to administer ‘wall CPAP’, and as there was no valve, Mr Kilbey suffered barotrauma - caused by the air pressure. He was found with a “grossly expanded chest” and he was “puce with no heartbeat”.

Forensic pathologist Dr Richard Shepherd conducted a post mortem examination and concluded the “ventilation equipment had been incorrectly put together” and Mr Kilbey had died as a result of barotrauma due to being exposed to “high pressure gases through the tracheostomy tube”.

The inquest heard that nurse Lesley Allen, who at the time of the incident had been a senior staff nurse for 12 years and a staff nurse in critical care for 18 years at Airedale, was looking after Mr Kilbey.

She had anticipated using WhisperFlow equipment for CPAP, which the inquest heard was being phased out, but when she went to the room where she expected to find it, it was not there, but another device called an Armstrong machine was there, which she had not used for this purpose before.

In concluding the hearing yesterday, Assistant Coroner Oliver Longstaff said providing CPAP to Mr Kilbey via this machine was “not a viable option” and it was not the intention of the hospital, at that stage, that it should be used to deliver CPAP to tracheostomy patients.

The inquest heard the WhisperFlow machines had been moved from their usual spot pending a CQC inspection under the rationale of making the place look tidier and when Ms Allen found they were not there, she assumed they had been disposed of.

Mr Longstaff highlighted the evidence of another nurse, who said she had challenged Ms Allen and her colleague Andrew Farrar, on the equipment and components they were attempting to set up the machine with and she had also told them the Armstrong machine should not be used for a tracheostomy patient.

Nevertheless, the machine was set up and Mr Longstaff concluded the incorrect assembly meant medical gases were passed at high pressure causing a fatal barotrauma.

He ruled it was a death due to an accident and said there was no evidence to suggest the machine set up, lacking the necessary valves, was a deliberate act by those involved.

“This must have been the most traumatic and frightening experience for all involved in it and I think the pain from it may last a very long time,” Mr Longstaff said.

His only surviving relative, cousin Linda Munnoch, said he had his own flat and had found a nice group of friends that he was enjoying being a part of.

“It’s so sad that has been taken away,” she said.

The inquest heard the hospital has taken steps following Mr Kilbey’s death to prevent anything similar happening in future.

Karl Mainprize, medical director at Airedale NHS Foundation Trust, said: “This was a tragic death and we apologise again to Mr Kilbey’s family for the deeply regrettable outcome. We are very sorry that our care for him fell short of our usual high standards.

“We have learned the lessons we can from this distressing incident. Following Mr Kilbey’s death we reviewed our critical care procedures in detail and made a number of significant changes. We have also worked closely with external partners to drive forward sustainable improvements in quality and safety on our critical care unit.”