A 19-year-old died after his brain was starved of oxygen for more than an hour, an inquest heard.

Emmanual Abiona, known as Shola, was born with cerebral palsy and suffered from respiratory problems as he got older.

The five-day inquest at Gravesend Old Town Hall heard that he had been fitted with a tracheostomy to keep his airway open.

The teenager, of Redwell Grove, Kings Hill, required 24-hour care, which had previously been provided by a carer, June Smith, during the day and his parents at night.

However, the family were advised to employ agency carers for night shifts and weekends, who were properly trained in tracheostomy care.

Debbie Field, a consultant nurse at Royal Brompton Hospital with 13 years experience in tracheostomy care, told the court one of the main risks is tubes can become dislodged, which can cause the patient significant discomfort.

Miss Field had visited Shola on a number of occasions to change the tracheostomy and noted he would become distressed as he could feel his trachea getting tighter.

Tragically, Shola’s tracheostomy came out while he was asleep in the early hours of Monday, May 30, 2016, while Karene Uuldersma, a carer provided by Pulse Community Healthcare, was monitoring him.

She called for help from his sleeping family and they made attempts to resuscitate him before paramedics arrived, who took him to Maidstone Hospital.

“In the moment of confusion I did try my best to do what I could from what I remembered" - Karene Uuldersma

Doctors found Shola had gone into cardiac arrest and his brain had been starved of oxygen for more than an hour.

He died on Wednesday, June 1.

During the hearing, questions were asked about the standard of care Miss Uuldersma had provided, with Anthony Metzer, the legal representative for the family, highlighting many protocols the carer had breached.

Miss Uuldersma said although she had been trained in how to reinsert tubes on a dummy, she had never changed the whole tracheostomy on any patient and had never experienced an emergency situation such as this.

She said: “In the moment of confusion I did try my best to do what I could from what I remembered.”

Concluding, Chris Morris, assistant coroner for Mid-Kent and Medway, ruled his death was accidental, contributed to by neglect.