A misplaced breathing tube contributed to the death of 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, caused by Covid pneumonia, in the early hours of March 30, 2020. The 13-year-old had a cardiac arrest before he died, three days after testing positive.
Hours before his death, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position and a consultant in paediatric intensive care decided to leave it and monitor him. 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.
Ismail's family were not able to be with him when he died in King's College Hospital and were unable to attend his funeral because they were self-isolating after some of his siblings experienced Covid symptoms.
Ismail Mohamed died aged just 13 - pictured is his funeral when Covid guidelines were in place
He died after contracting the virus at the beginning of the pandemic in March 2020 - around a week after the first nationwide lockdown was announced
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'.
King Charles, then the prince of Wales, said in April 2020 he was 'utterly heartbroken' by the teenager's plight.
Mr Harris said 'misplaced ET' and 'high BMI' should be recorded under acute respiratory distress syndrome and Covid pneumonia on his 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 by Ismail's eldest sister, read out in court, described him as a 'kind and genuine soul'.
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.
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.
When asked during her evidence on Wednesday about 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.'
The extraordinary scenes at Ismail's funeral are a poignant reminder of the devastation caused by coronavirus across the UK
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 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'.
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.'
Dr Khatri told the court on Wednesday 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 told the court yesterday 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. The coroner accepted this as the most likely explanation.
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.