A DOCTOR is baffled as to why a pensioner could not be ventilated effectively following an operation before going into cardiac arrest, he told an inquest.

Maureen Robson was fitted with a tracheostomy tube to ensure a reliable airway was retained before and after mouth cancer surgery at Worcestershire Royal Hospital.

However, having been transferred to the Intensive Care Unit following the surgery on November 6, 2017, the 77-year-old began having breathing problems before going into cardiac arrest and dying.

Speaking at an inquest hearing on Wednesday (February 27), Dr Steven Digby, the on-duty ICU consultant, said: “I do not know why we couldn’t establish ventilation, even though we had established an airway.

“There were a lot of things going on that we just couldn’t get on top of.”

Several medical staff members, who gave evidence at the hearing, reported the patient had been fine following the 12-hour surgery, with no major concerns about her condition or the tube.

Dr Samuel Marttine, lead surgeon, said the tube's placement was monitored throughout the operation, and Mrs Robson was recovering well the following day, even waving at him from her bed.

Dr Digby said initial concerns that there was a leak in and around the tube’s cuff – a pressurised balloon – were found to be incorrect during examination on November 7.

Amanda Portman, an ITU nurse in charge of Mrs Robson, said the patient was fine until 5.30pm on the day after the operation when she began to cough and became distressed.

“She was beginning to struggle with her breathing,” said the nurse, who has 17 years’ experience.

“I offered her suction [from a catheter] to see if there was any blockage in the trachea. I tried to pass the suction into the tube but it wouldn’t pass, there was resistance. It normally passes easily down a tracheostomy, but in this case it wouldn’t, [it just] passed a little way.”

Dr Digby, who had stepped in by this stage, said: “There was a blockage, but whether it was a displacement or something else I can’t say. Her oxygen levels were dropping down to 90 per cent.”

He said the tube had certainly worked its way out of the trachea but once it had been re-inserted and then a new airway “railroaded” and longer tube used, Mrs Robson was still unable to breathe.

Paul Geddy, a pathologist who performed the post mortem, gave the cause of death as hypoxia caused by “interruption” of the breathing mechanism.

“Something has gone wrong with the way the tube works but I don’t know what,” he said.

He said it had possibly become dislodged by Mrs Robson coughing but said there was no explanation as to why no airway could get through.

Dr Geddy said the tissue around the trachea was only mildly inflamed and on dissection there was no issue with the organ itself.

Andrew Evans, the barrister representing Mrs Robson’s family, asked whether the cuff leakage had potentially been more serious than first thought and had caused the problem.

Dr Digby said: “You can have cuff leaks for all sorts of reasons. Even if you’ve got no leak you could still displace the tube.”

He said he’d experienced a tracheostomy tube becoming displaced five times in his 25 years in the job and believed in this case Mrs Robson coughing had caused it – but that did not explain the ventilation issues afterwards.

Dr Gareth Sellers, who undertook a review, said there needs to be a national standard regarding how staff check the tube is inserted correctly in comparison to the corina of the trachea.

The court heard that the hospital now uses a scope to check the tube after it is inserted and also on arrival in ITU, rather than just when there’s a serious issue.

It was unclear what happened to the tube afterwards, but a family member of Mrs Robson said it should be tracked down for further analysis.

Coroner Geraint Williams adjourned the inquest until Thursday (February 28) when he will make his verdict.

READ MORE: We still have questions say family of pensioner who died after surgery following inquest