A MOTHER tragically died after a breathing tube was placed into her oesophagus instead of her windpipe, an inquest heard today.
Emma Currell, 32, had just received dialysis treatment and was heading home to Hatfield, Hertfordshire, in an ambulance when she suffered a seizure in 2020.
A sufferer of nephrotic syndrome, Emma required the procedure for the kidney disease which causes leakage of protein from the blood into the urine and a build-up of water in the body.
An anaesthetic team was called to sedate Emma after her tongue swelled up and she was experiencing bleeding from the mouth.
However, the tube, intending to be placed in her trachea, or windpipe, was erroneously placed in her oesophagus, the food pipe - resulting in a fatal cardiac arrest on September 5, 2020.
Following the inquest, Emma Currell's sister Lauren said: "Today was the hardest thing to bear for my family since Emma died. We're glad at least to have some clearer answers as to what happened.
'We will never get over Emma's death. The hospital has said that they have now put in place improved procedures and training to ensure this type of devastation never happens to anyone else. We trust they will fulfil their promise."
Dr Sabu Syed, a trainee anaesthetist, told the hearing: "Initially the tongue was incredibly swollen and a lot of blood was coming from the mouth. I used suction to remove blood and I was able to push the tongue to the side and got a partial view."
She said she believed she inserted the tube into the trachea, but now knows it was the oesophagus.
As she was inserting the tube, Dr Syed asked her senior colleague Dr Prasun Mukherjee to check the position of the tube.
Dr Syed said: "Dr Mukhejee was busy doing other tasks.
"I had a look myself. Unfortunately her tongue was more swollen."
Technician Nicholas Healey also expressed concern when there was no carbon dioxide reading on the ventilator, and wasn't faulty.
He said: "I was not confident the tube was in the right place.
"A couple of doctors listened to her chest and they were confident there was a reaction."
Dr Mukherjee told the hearing: "I had confidence in my colleague that the tube was appropriately placed."
Graham Danbury, the deputy coroner for Hertfordshire, queried: "Did you, with greater experience, consider that you should have done the administration?"
He replied: "It is difficult."
Dr Mukherjee said he still detected breathing after the tube was inserted and had presumed the issue lay with the monitor.
He said he was also concerned about the risks of removing the tube and the danger of surgery.
Asked if it had crossed his mind to summon a more senior colleague, he said: "I probably did not have enough time to ask for external help.
"Retrospectively and with hindsight we know the tube was in the wrong place."
The court heard the hospital had drawn up a guideline checklist for trachea procedures since Ms Currell's death and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion.
In a narrative conclusion, Mr Danbury said the carbon dioxide readings were not acted on for a "considerable" period of time.
He said: "It is accepted by the hospital that the tube was initially in the wrong place and Dr Mukherjee said action should have been taken sooner."