A woman with respiratory problems died at Kingston Hospital after her newly-inserted breathing tube shifted, an inquest has heard.

But doctors could not have done anything more to save her, an investigation found.

Isobel Edermaniger, 68, who lived in Chessington, died on January 1 from complications following an operation to insert a tracheostomy tube.

But the tube shifted, and doctors trying to replace it found Mrs Edermaniger’s breathing difficult to stabilise after her condition deteriorated at about 4am.

A hospital investigation, headed by Dr Anne Blythe, said measurements should now be taken when inserting tracheostomy tubes.

Dr Blythe told West London Coroner’s Court on Wednesday: “That was the only recommendation that we could make to improve our practice. She was a very difficult patient to manage.

“She had absolutely no [respiratory] reserve.”

Mrs Edermaniger’s breathing difficulty and high body mass index meant when she was moved, or when doctors tried to move her tracheostomy tube, her body could not retain as much oxygen as most patients.

She had been on a ventilator for some time before the operation.

She slept sitting up at home, Dr Blythe added.

The surgeon who operated on Mrs Edermaniger, Parag Patel, said the procedure went “very smoothly” and post-operative x-rays were positive. The tracheostomy was “a necessity for the patient’s management”, he said.

But Mrs Edermaniger’s husband, David, told the court he was concerned his wife’s septicaemia was not picked up by doctors in repeated trips to accident and emergency.

He said: “Should that have been picked up so many months before?

“Why was the cellulitis [a deep skin infection in the legs] not treated by anybody for the months previous?”

Dr Blythe said: “Septicaemia is extremely difficult to diagnose. It is only when it gets to a critical point that actually you start to pick it up.”

Coroner Chinyere Inyama concluded: “Isobel Mary Edermaniger died as a result of her necessary surgery. Her general frailty of health was a considerable co-factor.”

Mrs Edermaniger died of respiratory failure and septicaemia, the latter likely caused by existing cellulitis, the court heard, which were complicated by the shifting of her breathing tube.

Secondary causes were listed as morbid obesity and pulmonary hypertension.