THE family of a pensioner who died following complications in the aftermath of surgery have said further investigation is needed as there are still “many questions left unanswered”.

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.

Giving his verdict on Thursday (February 28), coroner Geraint Williams said Mrs Robson “died as a result of a known albeit rare complication following necessary surgery”.

He said pathologist Dr Paul Geddy in his post mortem report gave cause of death as hypoxia caused by the interruption to and malfunction of the breathing device.

Mr Williams clarified that a “malfunction does not suggest there was anything physically wrong with the tube, rather the tube had failed to work”.

“I propose the underlying cause was displacement rather than malfunction, as in my judgment this reflects more accurately what happened.”

The coroner went on to say that the displacement of the tube resulted in “obstruction which clinicians in the care of her were unable to resolve”.

He said sometime after 5pm on November 7, some 17 hours after the surgery was completed, Mrs Robson had begun to cough and become agitated.

Dr Steven Digby had tried to access the trachea via the tube but it was “immediately obvious that the tube was not in the trachea”.

Mr Williams said questions surround the tube’s displacement but was happy to accept as fact it had come about when Mrs Robson began coughing, as there had been “no difficulty breathing in the entirety of the prior day”.

“There was no issue regarding the displacement before the coughing and it was coughing that displaced the tube and thus obstructed her airway.”

On the previous day of the inquest, Dr Steven Digby, on-duty ICU consultant, had told the court the tube was refitted into the trachea, but Mrs Robson was still unable to breathe.

“I do not know why we couldn’t establish ventilation, even though we had established an airway,” he said.

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.

Mrs Robson’s son Simon Smith said even though he is “devastated” by the loss of his mum, “out of that a policy change has come that’s going to benefit other people”.

Asked about the lack of clarity around what the blockage was, seeing as no such reason had been found in the post mortem, he said: “There still remains a lot of unanswered questions that still need to be looked at.”

“For me, it’s the actual cause of death as a coughing incident and displacement of the tracheostomy tube.

“That’s still an issue that needs to be explored more and the process of care following the operation to the ITU and the checks that should have been first issued.”

He said certain aspects had been clarified after hearing the evidence for which he was grateful but felt “an investigation needs to be carried out”.

Mrs Robson’s daughter, Rebecca Mount, said: “I find it difficult to understand and digest that an exact cause of death hasn’t been determined and they haven’t got to the bottom of why this blockage was found – what was the cause of it?

“It remains a mystery at this point, all the medical expertise in the room and we still can’t get to the bottom of why there was this blockage. I find it very hard to comprehend.”

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