'Ventilator error' killed woman at Oxford hospice
A 21-year-old woman with a rare disease died when staff at a hospice failed to replace part of her breathing tube, an inquest has heard.
Emily Bushaway "turned blue" after part of her ventilator, known as a whisper valve, was seemingly discarded at Helen & Douglas House in Oxford.
Her father Mark Greener said he noticed the part was missing when he came to take her home.
Coroner Darren Salter recorded a narrative verdict.
He concluded staff had not been suitably trained in invasive ventilation and were unfamiliar with the valve.
He said the serious risks were not adequately highlighted in the patient's care plan, so her accidental death was contributed to by neglect.
The coroner also recommended the hospice improve areas of training in ventilators.
Ms Bushaway, who was from Letchworth, was having several days of respite care in May 2016.
She was diagnosed at six years old with the neuro-degenerative condition Niemann-Pick disease type C.
Mr Greener told the inquest her ventilator was attached directly to a plastic breathing tube connected to her windpipe.
Its whisper valve needed washing and changing daily, and allowed Ms Bushaway's body to get rid of carbon dioxide.
Mr Greener explained the ventilator was hooked up to a screen which displayed a "no-flow" alarm.
The court heard that on 14 May its message log showed the alarm had been triggered three times in 13 minutes.
Shortly after, Mr Greener arrived to find his daughter in her wheelchair looking "awful" with blue fingernails and lips.
He told the inquest: "They [the staff] were woeful. I walked in there and they were standing there doing nothing."
A post-mortem examination found Ms Bushaway died of "severe respiratory compromise due to a failure of the ventilator function".
The family's lawyer, Tim Deeming, said: "Such a tragic, avoidable death has understandably shocked the whole family. Whilst Helen & Douglas hospice can provide supportive care, on this occasion they have let the family down though such systemic failures."