A misplaced breathing tube contributed to the death of a 13-year-old boy who became the UK’s first known child victim of coronavirus, a coroner has ruled.
Ismail Mohamed Abdulwahab, of Brixton, south-west London, died of acute respiratory distress syndrome (ARDS), caused by Covid-19 pneumonia, in the early hours of March 30 2020, three days after testing positive for the coronavirus.
He had a 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.
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.
I am satisfied that (Ismail) would not have died when he did were it not for the tube misplacement
The teenager did not survive the night.
Senior coroner Andrew Harris said: “I am satisfied that he 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.
A statement made by Ismail’s eldest sister, read out in court, described him as a “kind and genuine soul”.
Once we arrived (at the hospital) we were met with the dreadful, shocking and sad news of (Ismail's) passing. We are overwhelmed with grief by his passing
He was admitted to hospital on March 26 2020 after experiencing fever, coughing, shortness of breath, vomiting and diarrhoea.
The next day, he was put into intensive care and tested positive for Covid-19.
His sister told the inquest a phone call was received hours before Ismail’s death asking for a family member to go to see him.
“Once we arrived, we were met with the dreadful, shocking and sad news of his passing,” she said.
“We are overwhelmed with grief by his passing.”
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.
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. It was a real oversight ...
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.
Dr Vince told the coroner Ismail was “improving” at the time and she felt it was a “safer option” to leave him be and monitor him.
Mr Harris found that the consultant’s decision was made based on inadequate information after her “admitted failure” to inspect the tube’s position on the X-ray.
He said it was Dr Vince’s evidence that she would have pushed the tube down had she appreciated its “true position”.
At a basic level, clearly the fact that the tube was not in the correct place has contributed to (the cardiac arrest)
Dr Vince told the inquest it would be “reasonable to consider” putting the misplacement of the breathing tube on the death certificate.
Asked by the coroner what the cause of Ismail’s cardiac arrest was, Dr Vince said: “At a basic level, clearly the fact that the tube was not in the correct place has contributed to this.”
Giving evidence on Wednesday, Dr Khatri told the court he did not agree with his colleague’s decision not to adjust the tube but accepted he did not challenge it.
Professor Akash Deep, a leading paediatric consultant, said the “dislodged” tube was the “tipping point” for Ismail’s death.
He said during his evidence on Wednesday, and this was accepted by the coroner as the most likely explanation, that movement of Ismail could have caused the breathing tube to reposition higher up the boy’s trachea and curl in the back of his mouth without changing its position externally.
Mr Harris said the hospital was under “unprecedented pressures” from the first wave of the pandemic and that, despite “demands previously unknown” and “understandably terrified” staff, Ismail was provided with continuous intensive care.
He said he hopes the inquest will allow the family to “rebuild” their lives.
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