A misplaced medical tube contributed to the death of the first child in the UK to die after contracting Covid, a coroner has found.
Ismail Mohamed Abdulwahab, 13, of Brixton, south London, died of acute respiratory distress syndrome, caused by Covid-19 pneumonia, on 30 March 2020, three days after testing positive for coronavirus. He had a cardiac arrest before he died.
Ismail’s death prompted widespread alarm about the potentially lethal impact of Covid on children. Public shock at his death was compounded when it emerged that his immediate family, including six siblings, could not attend his funeral because they had to self-isolate under Covid lockdown restrictions.
Hours before Ismail died, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position. A consultant in paediatric intensive care decided to leave it and monitor him.
Giving his judgment on Thursday, 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.”
On Wednesday, the inquest at London Inner South London coroner’s court heard evidence from Dr Tushar Vince, a consultant in paediatric intensive care at King’s College hospital who treated Ismail on 29 March after he had been intubated.
Asked by Harris if it would be reasonable to put the positioning of the ET on the death certificate as one of the causes, Dr Vince said: “I think it would be reasonable to consider it, yes.”
She said: “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.”
The court heard that another paediatric doctor, Anuj Khatri, had pointed out to Vince at about 9.30pm that the tube was too high but, after a conversation about the risks of moving or not moving the ET, she decided not to reposition it.
The court heard that Ismail was “improving” at the time.
During his evidence, Khatri told the court he did not agree with his colleague’s decision not to move Ismail on to his back so the tube could be adjusted.
He said he believed the situation was “urgent” because the highly placed tube could get dislodged which was “potentially life-threatening for a patient who is sedated and paralysed” on muscle relaxants.
Vince told the court a dislodged tube in previously fit and healthy children should not “easily” lead to cardiac arrest.
“So is it actually he was much sicker than we thought?” she asked.
In a provisional opinion given on Wednesday, Harris said “neglect” could not be applied to the incident.