A misplaced breathing tube contributed to the death of a 13-year-old boy who was named as the first child victim of Covid, a coroner has ruled.

Ismail Abdulwahab, of Brixton, south-west London, suffered a cardiac arrest and died of acute respiratory distress syndrome, caused by Covid-19 pneumonia, in the early hours of March 30 2020 – three days after testing positive for Covid.

His death during Britain’s first lockdown caused widespread fears that the virus was more deadly for healthy children than first thought, with scientists warning that not following the guidance to stay at home and stay away from people could lead to the loss of a child.

Dr Simon Clarke, an associate professor in cellular microbiology at the University of Reading, said at the time: “This is a reminder that we must take the advice of health officials seriously to stay at home, wash hands and keep well away from all other people. 

“The message so far has seemed to be that by following the guidance, you might save the life of a cherished parent or grandparent. This case could yet remind us that staying home could also save the life of a cherished child or grandchild too.”

Displaced tube ‘triggered cardiac arrest’

In the previous weeks, Prof Sir Chris Whitty, the Chief Medical Officer, also warned against becoming “complacent” by thinking healthy children were immune from the disease.  

However, the inquest heard that hours before Ismail’s death, an endotracheal tube used to help patients breathe was found to be in the wrong position.

Andrew Harris, the senior coroner, said: “I am satisfied that he would not have died when he did were it not for the tube misplacement.”

He said that the tube becoming displaced was “the trigger” that led to Ismail’s “unexpected” cardiac arrest.

Mr Harris also said that high body mass index should be recorded on the death certificate.

Ismail’s family members were not able to be with him when he died in King’s College Hospital, south London, and were also unable to attend his funeral because they were self-isolating after some of his siblings experienced Covid symptoms.

Doctor admits not seeing misplaced tube

In April 2020, four people wearing protective clothing, gloves and face masks lowered his coffin into a grave in south-east London.

Ismail 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.

The inquest heard from Dr Tushar Vince, a consultant in paediatric intensive care at King’s College Hospital, who treated Ismail on March 29 after a breathing tube had already been inserted.

In the inquest, she admitted that despite seeing an X-ray of Ismail’s chest, she did not spot that the tube had been wrongly inserted.

Dr Vince said: “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.

“It was a real oversight that I did not see the tip of this tube.”

Pandemic pressures

Anuj Khatri, another paediatric doctor, pointed out to Dr Vince that the tube was too high but, after a conversation about the risks of moving and not moving the tube, she decided not to reposition it, the court heard.

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.”

Prof Akash Deep, a leading paediatric consultant, said that the “dislodged” tube was the “tipping point” for Ismail’s death.

Mr Harris said the hospital was under “unprecedented pressures” from the first wave of the pandemic.

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