A Norfolk hosptial has admitted the death of one of its patients was "avoidable" after a blunder involving his breathing apparatus led to him being asphyxiated. 

Carl Billimore died at the age of 55 while being treated at the Queen Elizabeth Hospital in King's Lynn, an inquest heard.

Mr Billimore, a window cleaner from Littleport near Ely, suffered from blocked airway as a result of an error related to his tracheotomy. 

He had been transferred to the QEH from Papworth Hospital in Cambridgeshire, where he was admitted on December 15, 2022, after suffering a cardiac arrest.

While at the Papworth, a tracheotomy was fitted to manage his breathing, with an inflated cuff fitted to seal off his airway - which required deflating when a speaking valve was switched on to allow him to communicate.

However, on January 9, 2023, the speaking valve was inserted without the cuff being deflated - blocking his airways and causing him to suffer asphyxiation.

A serious incident investigation conducted by the QEH and read out to the court concluded that his death had been avoidable.

Jacqueline Lake, senior coroner for Norfolk, concluded his death to have been misadventure.

The court heard that since Mr Billimore's death, the trust had placed warning signs on all tracheotomy equipment reminding staff to deflate cuffs before using speaking valves.

Following the inquest, Pippa Street, the trust's chief nurse, said: "On behalf of the trust I would like to express my full and sincere condolences to Mr Billimore's family.

"We are sorry the care he received fell below the standard we would expect to provide and which our patients deserve.

"A full investigation has taken place and a robust action plan has been produced, including enhanced learning using simulation training to improve confidence in the care of tracheotomy patients.

"We have invested a significant amount of resources into ensuring that we learn from this sad incident and that it will not happen again."