Retired electrician, Keith Woodroff died at Hinchingbrooke on May 5 last year after being admitted to the hospital on April 24 with pneumonia.Keith, 74, underwent a tracheostomy in an attempt to wean him off a ventilator on May 4. However, following the procedure, Mr Woodroff rapidly deteriorated and died in the early hours the next day. An internal hospital investigation found that part of his treatment was not appropriate for his condition at the time. A three-day inquest into Keiths death was held at Huntingdon Coroners Court between October 9-11, where assistant coroner for Cambridgeshire Rosamund Rhodes-Kemp heard evidence from Mr Woodroffs family, two expert clinicians, and staff at the North West Anglia NHS Trust, including Dr Muhammad Asif, the consultant responsible for his care. The evidence addressed the pattern of decision making leading to the procedure and the complications arising from it. In her conclusion, Mrs Rhodes-Kemp acknowledged that there had been errors in the way in which Mr Woodroffs care was managed, highlighting in particular that the planning and documenting of Mr Woodroffs treatment had been poor. The coroner recorded a verdict of misadventure. After his death, Keiths family instructed specialist lawyers at Irwin Mitchells Cambridge office to investigate the care he received and to support them through the inquest. Gurpreet Lalli, the solicitor at Irwin Mitchell, representing the family, said: This is a truly devastating incident in which a family has lost a much-loved husband and father. The inquest has provided vital information regarding the care that Keith received and we are concerned by a number of issues which have been raised. We hope that lessons are learnt and the trust implements changes in order to avoid the loss that Keiths family have suffered. The inquest heard that prior to his illness, Mr Woodroff was a fit and active man who regularly would help his friends and his neighbours in and around the community. Expert critical care consultants, Dr Stuart Booth, who contributed to the internal hospital investigation, and Dr Ken Power, from whom the coroner sought expert opinion prior to the inquest, attended and gave oral evidence. The inquest heard that Mr Woodroff was critically unwell during the procedure. Both experts agreed that a tracheostomy was premature and that Dr Asif should have given Mr Woodroffs condition a chance to improve before proceeding. Dr Power described Dr Asifs decision as an error of judgment and Dr Booth said there was zero benefit of performing a tracheostomy at that time. Several hours later doctors realised that Mr Woodroffs trachea had been damaged as his condition rapidly deteriorated. However, no attempt was made to call for assistance or to repair the damage caused and Mr Woodroff suffered a cardiac arrest and died in the early hours of May 5. Ann, 72, who has four adult-children with Mr Woodroff, said: Going through the inquest process has been incredibly difficult, particularly learning of the flaws in Keiths treatment. Ann added: While it is obviously too late for Keith, we are now hopeful that we can ensure lessons are learned from what happened to him so that it doesnt happen to anyone else. Dr Kanchan Rege, medical director for North West Anglia NHS Foundation Trust, said: The circumstances surrounding Mr Woodroffs death were investigated thoroughly by the trust and the findings were presented at the inquest. After hearing both factual and expert evidence over three days, the coroner arrived at a conclusion of misadventure. Sadly, Mr Woodroff passed away from a complication of a percutaneous tracheostomy, a procedure that was believed to be in his best interests at the time. We would like to express our sincere condolences to the family for their loss.