A TERMINALLY-ill man was on the incorrect ventilator when he died at his mother's Chandler's Ford home, an inquest has heard.
Since Matt Simmonds' death on July 6, 2011, a series of procedural changes and extra training have been implemented at Southampton General Hospital's Respiratory High Dependency Unit.
Giving evidence at the Winchester inquest this morning, respiratory consultant Dr Jane Wilkinson said: “It (the ventilator) shouldn't have been used for longer periods than 20 hours.
“We became aware of this so a plan was put in place. But it should have triggered a review of the kind of ventilator being used and a change of ventilator made.”
Matt Simmonds was dying from a rare genetic condition called von Hippel-Lindau disease, which had caused tumours to grow in his neck and brain.
He was unable to breathe without the aid of a ventilator and doctors expected him to die “within days or weeks”.
But Royal Hampshire County Hospital pathologist Dr Amanda Jeffery, who conducted the post mortem, said that Matt had died after “about an hour of no ventilation” at his mother's home in Oakmount Road.
The inquest heard that an extensive criminal investigation was carried out but no charges were eventually brought.