The misplacement of a breathing tube was a factor in the death of the UK’s first child victim of Covid, a coroner has concluded.
Ismail Mohamed Abdulwahab was 13 when he was rushed to King’s College Hospital in London with symptoms including fever, coughing and vomiting on March 26, 2020.
Due to hospital policies at the time, his family was not able to visit him in intensive care when he was moved there the following day.
Ismail, from Brixton in south-west London, died of acute respiratory distress syndrome caused by coronavirus pneumonia on March 30 – three days after he tested positive.
Images of his funeral, which the family were unable to attend as they were self-isolating, circulated widely in the early days of the Covid lockdown.
They showed his coffin being lowered into a grave by four people wearing white protective clothing, gloves and face masks.
Hours before Ismail’s death, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position and a decision was made by a consultant in paediatric intensive care to leave it and monitor him.
Senior Coroner Andrew Harris told an inquest into the boy’s death: ‘I am satisfied that he would not have died when he did were it not for the tube misplacement.’
However, he made it clear that although the tube’s positioning contributed to Ismail’s death, he did not find that the boy would not have died at another time had there been no misplacement.
The coroner said: ‘Ismail died from complications of necessary medical treatment for a natural disease.’
Mr Harris said ‘misplaced ET’ and ‘high BMI’ should be recorded under ARDS and Covid-19 pneumonia on the boy’s death certificate.
The inquest at London Inner South Coroner’s Court heard that hospital staff disagreed over whether the misplaced tube should be moved.
Dr Tushar Vince, a consultant in paediatric intensive care at King’s College Hospital where Ismail was being treated, made the decision not to move it, as the boy was lying on his front and doing so would mean flipping him over.
During his evidence, Dr Anuj Khatri, another paediatric doctor, told the inquest he did not agree with his colleague’s decision.
Mr Harris said the hospital was under ‘unprecedented pressures’ from the first wave of the pandemic.
He added that, despite ‘demands previously unknown’ and ‘understandably terrified’ staff, Ismail was provided with continuous intensive care, and said he hopes the inquest will allow the family to ‘rebuild’ their lives.
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