A NURSE tearfully gave evidence at the inquest of a 60-year-old man who died unexpectedly at Airedale General Hospital after the wrong equipment was used in an effort to help him breathe.

The three-day hearing, at Bradford Coroners’ Court, previously heard Geoffrey Kilbey, of Hillworth Village, Oakworth Road, in Keighley, had “blown up like a balloon”.

He was admitted to the hospital with pneumonia and respiratory failure after collapsing in the street in March 2016 and 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. He was found with a “grossly expanded chest” and he was “puce with no heartbeat”.

Forensic pathologist Dr Richard Shepherd conducted a post mortem 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”.

Yesterday’s hearing heard 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 and was asked to undertake wall CPAP.

She said she had anticipated using WhisperFlow equipment, 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, with an equipment bag on the drip stand.

Ms Allen said her colleague Andrew Farrar identified the wrong tubing was in the bag and went to go and get the correct sort. When asked by Assistant Coroner Oliver Longstaff if she would have recognised it was the wrong tubing herself, she said she would have done, and said the tubing her colleague brought back was for the Armstrong machine.

The importance of a CPAP valve and a safety valve for the sake of patient safety was highlighted in the evidence, but neither of those valves were present in the assembly set up. Ms Allen had asked Mr Farrar to check the set up as she wanted “an extra pair of eyes on it” as it was a relatively new machine.

Earlier evidence heard the Armstrong machine should only be used for CPAP using a mask or a hood - and not a tracheostomy. When questioned on that, Ms Allen said it was her understanding from the rep that the machine would do everything the WhisperFlow could do. She had used the Armstrong machine “a couple of times”, but in high-flow capacity and when asked if she’d had training, Ms Allen said she’d had a demonstration from a rep.

Mr Kilbey’s only surviving relative Linda Munnoch said more checks should have been in place and more people should have been involved in putting together the machine. The case was referred to the CPS, but no criminal charges will follow. The inquest concludes today.