A misplaced breathing tube contributed to the death of the UK's first known child to die from Covid, a coroner has found. Ismail Mohamed Abdulwahab, from London died from acute respiratory distress syndrome caused by coronavirus just three days after he first tested positive in March 2020. However, hours before his death, a breathing tube was found to be in the wrong position and a consultant made the decision to leave it. The coroner said he was "satisfied" that the 13-year-old would not have died when he did "were it not for the tube misplacement.
Senior Coroner Andrew Harris said: "I am satisfied that he (Ismail) would not have died when he did were it not for the tube misplacement."
He said the tube becoming displaced was "the trigger" that led to Ismail's "unexpected" cardiac arrest.
Mr Harris said "misplaced ET" and "high BMI" should be recorded under ARDS and Covid-9 pneumonia on Ismail's death certificate.
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.
"Ismail died from complications of necessary medical treatment for a natural disease," the coroner said.
The inquest heard from Dr Tushar Vince, a consultant in paediatric intensive care at King's College Hospital, who treated Ismail, already intubated, on March 29.
The court heard she saw an X-ray of Ismail's chest.
Asked during her evidence on Wednesday what it showed about the position of the tube, she said: "It's too high.
"I fully accept I just didn't see. I was so focused on the lungs I just didn't see how high this tube was and I'm so sorry that I didn't see it."
She added: "It was a real oversight that I did not see the tip of this tube."
Another paediatric doctor, Anuj Khatri, pointed out to Dr Vince that the tube was too high but, after a conversation about the risks of moving and not moving the ET, she decided not to reposition it, the court heard.
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Ismail first fell ill on March 23, 2020 but his sister said his breathing worsened two days later and he was taken to the hospital suffering a fever, shortness of breath, vomiting and diarrhoea.
The next day he was put into intensive care after testing positive for Covid.
Ismail suffered cardiac arrest before he died.
Ismail's family members were not able to be with him when he died in King's College Hospital and were also unable to attend his funeral because they were self-isolating after some of his siblings experienced Covid symptoms.
Four people wearing protective clothing, gloves and face masks lowered his coffin into a south-east London grave in April 2020.
Matt Hancock, who was the health secretary and the father of a 13-year-old child himself, said Ismail dying without a parent at his bedside "made me weep".
And King Charles, then the prince of Wales, said in April 2020 he was "utterly heartbroken" by the teenager's plight.