Christ Morrison

“It was not clear what level of training was necessary for the staff changing tracheostomy tubes of children at home. The mother was very concerned that this should be performed by a nurse without medical presence.”

“It was also submitted at inquest that in the event of failure to replace a tube, the health care professional should be skilled and equipped to perform a new emergency tracheostomy. This was not the position in this case.”

“processes for changing tubes has changed since this inquest, with two staff as a minimum now being required to be present, the court was informed that the Epsom and St Helier Paediatric Tracheostomy Policy complied with processes complied with other Trusts. But it makes clear that failure to reintubate requires emergency transfer to AGE rather than emergency tracheostomy and does not require a medical presence.”