Poor tracheostomy care warning
Gaps in training may put patients with tracheostomies in life-threatening situations, the NHS in England, Wales and Northern Ireland is warned.
The tubes are fitted to allow patients to breathe and are being used more frequently in hospitals.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report called for improvement.
The Intensive Care Society said care was sometimes "below what is safe and reasonable".
A tracheostomy is used to help wean patients off ventilators and get them out of critical care beds and on to general wards.
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