Hospital patient died unexpectedly after he 'blew up like a balloon' when the wrong equipment was used, inquest told

Geoffrey Kilbey was admitted to the hospital with pneumonia and respiratory failure after collapsing in the street in March 2016.

An inquest in Bradford heard how Mr Kilbey, of Hillworth Village, Oakworth Road, in Keighley, 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 consultant agreed to perform a tracheostomy 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.

In a statement Mr Kilbey's only surviving relative, cousin Linda Munnoch, described how she visited him two days before his death and had left the hospital feeling positive.

On April 19th, she rang to check on his condition and was told by a matron that there had been a tracheostomy incident and he had passed away.

"He said he was so, so sorry and it was all their fault," her statement said.

Forensic pathologist Dr Richard Shepherd conducted a post mortem examination which outlined how the tracheostomy was "uneventful" and the tube was sited correctly, but when CPAP was administered he "blew up like a balloon and went into asystole" - his heart stopped.

He was certified dead shortly before 4pm - around four hours after the tracheostomy.

Dr Shepherd concluded that "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".

Dr John Scriven, the consultant anaesthetist at Airedale General Hospital, described how he had carried out the succesful tracheostomy procedure.

He then instructed nurses to try CPAP for up to two hours in a bid to wean him off the full ventilation. He did not specifically request they use a WhisperFlow system, it emerged during the inquest, but said this equipment had been used at the hospital for the last ten to 15 years.

Of the moment he realised something was wrong, he said: "There were screams from the ICU - and someone shouting, 'Where's John?"

He found Mr Kilbey with a "grossly expanded chest" and he was "puce with no heart beat".

"I think the problem was that the lungs had exploded and he had a chest full of air," he added.

He told assistant coroner Oliver Longstaff: "I have never seen somebody with barotrauma before."

Staff nurse Audrey Hocaniuk was treating the patient in the next ICU bed to Mr Kilbey that day. Now retired, she gave evidence to the inquest about a new piece of equipment, known as an Armstrong machine, that the ward had begun using.

The WhisperFlow equipment had been "phased out" she said, and staff had been given demonstrations and training on the new equipment. But she added that the new machine should only be used for CPAP using a mask or a hood - and not a tracheostomy.

The inquest heard that Ms Hocaniuk queried the matter with her colleagues Lesley Allen and Andrew Farrar as they cared for Mr Kilbey.

She reminded them that they would need to resort to the older WhisperFlow device, and was assured that it was in hand.

Ms Allen is expected to give evidence at the inquest today.