A VULNERABLE patient died at Helen & Douglas House after a nurse mistakenly binned a vital part of her breathing tube, an inquest heard.

A coroner has ruled Emily Bushaway died partly due to neglect at the much-loved Oxford hospice, after the fault led to her suffocation on May 14 last year.

The 21-year-old's dad Mark Greener desperately tried to save his daughter, who was staying at Douglas House in Magdalen Road, after spotting the ‘woeful’ error.

Nurse Katie Philips, who has 20 years nursing experience, had accidentally unscrewed a valve on her ventilator and initially ignored the machine’s warning alarms. 

A statement issued by Mr Greener and partner Lisa Bushaway said the memory of their daughter's death will 'haunt them forever'.

They said: "We had complete faith in the care home we had chosen for Emily and believed she was being looked after under the highest of standards.

"Our beautiful daughter’s health was improving and she was gradually being weaned off her ventilator because she was doing so well.

"We are utterly devastated and bereaved at the tragic loss of our daughter."

Miss Bushaway, who lived in Hertfordshire, had a rare genetic condition called Niemann-Pick disease, which meant she was wheelchair-bound and unable to walk or talk.

She was diagnosed aged six and just 70 people are thought to have the disease in the UK, including her sister. 

Her family had booked her in for a week of respite at the hospice from May 9 until May 14, while 48-year-old Mr Greener decorated her bedroom as a surprise.

It was Miss Bushaway's ninth time at the hospice, but she had become reliant on an invasive ventilator since her last visit, which allowed her to breath through tubes connected to a tracheostomy. 

Several Douglas House nurses said at the inquest they had never before encountered the whisper valve on the machine, which required regular cleaning, and no one checked that they were competent to deal with its complexities.

One nurse said she was forced to Google what it did after Miss Bushaway's care plan - compiled by a student nurse - failed to draw attention to its importance.

But Mr Greener stressed he had rang the hospice three times ahead of his daughter's visit to check they were confident with her new equipment, and said Miss Bushaway's home nurses had given two staff members a demonstration of the valve upon arrival. 

Nurse Philips was preparing Miss Bushaway for home time on the morning of May 14 when she replaced the tube on her ventilator.  

She made a fatal error by taking the tube apart at the wrong point - removing half of the plastic valve, which was crucial in enabling Miss Bushaway to breathe out.

Mr Greener coincidentally arrived at the hospice at the very moment staff rang him in a panic. 

Speaking at the inquest at Oxford Coroner's Court on Wednesday, he said: "I jumped out and ran into Douglas House and a lady met me. 

"She was frantic, like a rabbit in headlights. She didn't know what to do. 

"When I got into Emily's room there was a lady [Ms Philips] just stood there - she wasn't doing anything. 

"It was woeful - no one had dealt with it. 

"Emily was white as white. In my whole life I've never seen her that colour or looking so ill. I could see her nails were blue."

After investigation by himself and members of his home nursing team, who were also present to pick Miss Bushaway up, he realised the breathing circuit was incomplete.

He added: "I told the nurse I needed a whisper valve and she said 'what's that.'"

Ms Philips told the court she was 'not confident' about changing the valve but wanted to replace the tube as it had gathered condensation. 

She said: "I left the valve because I thought it was safer. I wasn't intending on touching it because I didn't know how it came apart. 

"I didn't feel that I'd made a mistake. It slotted back perfectly." 

She initially muted the machine's warning alarm, which sounds when something is wrong, until 45 minutes later when she noticed her patient's breathing was inconsistent.

She assumed there was a blockage and tried to unblock the tube but the warning alarm continued to blare, until she called for colleagues' help and an ambulance. 

One of Miss Bushaway's home nurses told the court that disconnecting the tube for cleaning and reassembling it was a 'simple' task provided the nurse was properly trained.

Ms Philips's boss Elizabeth Leigh, director of clinical services at the court, stressed changes had been made since the tragedy.

She told the court: "We have completely reinvented our training."

Oxfordshire coroner Darren Salter ruled a narrative verdict of 'accidental death contributed to by neglect'.

He said he would raise concerns about the ease of incorrectly disassembling the valve to the Medicines and Healthcare Products Regulatory Agency. 

Police were investigating corporate manslaughter but the Crown Prosecution Service has ruled there is insufficient evidence. 

The family’s lawyer Tim Deeming said: “Mark and Lisa had strived to provide the best possible care for their daughters.

"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.

"Nothing can mask the pain the family have, and are still going through, but we hope this inquest will help put effective measures in place to safe guard other families throughout the country, and make sure the highest standard of care is delivered everywhere.” 

Health inspectors at the Care Quality Commission rated the hospice's safety 'inadequate' in a report released earlier this year, noting an incident with a ventilator.

The hospice is expected to make a statement following the inquest.