While hospitalized, this mentally infirmed woman had to have a tracheostomy. The trach tube is something that requires regular maintenance and must occasionally be suctioned clear by a device made just for this purpose.
The problem here was that the patient was mentally infirmed. She could not even read or write. The medical staff simply came to her room, handed her the specialized equipment and told her how it works. Nothing more. Neither did the caregivers even ask the woman to demonstrate her proficiency with the cleaning device. Of course, had they tried, she would not have been able to do so.
With six hours of being sent to her home, she was dead. Her clogged trach tube and her frantic efforts to operate the device sent home with her were found by her side. What a needless tragedy. A confidential settlement was reached following litigation.