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Breathing tube error contributed to death of UK's first known child Covid victim, coroner rules


A misplaced breathing tube contributed to the death of a teenage boy who became the UK's first known child victim of COVID, a coroner has found.

Ismail Mohamed Abdulwahab, 13, of Brixton, southwest London, died of acute respiratory distress syndrome (ARDS), caused by COVID-19 pneumonia on 30 March 2020.

He died at King's College Hospital, London, three days after testing positive for the virus.

Hours before his death from a cardiac arrest, an endotracheal tube (ET), which helps 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.

A consultant in paediatric intensive care, Dr Tushar Vince, treated Ismail on 29 March after he had been intubated, the inquest heard.

Dr Vince said the fact that the breathing tube was in the wrong position could have contributed to the teenager's death.

Asked by the coroner 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."

Another paediatric doctor, Anuj Khatri, had pointed out to Dr Vince that the tube was too high but she decided not to reposition it, the court heard.

Dr Vince told the coroner that she had had to consider the consequences of intervening when Ismail was in a prone position, on his front, and concluded that it was the "safer option" to leave and monitor him rather than flip him on to his back to move the tube.

During his evidence, Dr Khatri told the court he had not agreed with his colleague's decision.

He said he had believed the situation was urgent because the position of the tube meant it could become dislodged, which was "potentially life-threatening for a patient who is sedated and paralysed" on muscle relaxants.

A paediatric consultant, prof Akash Deep, said the "dislodged" tube was a "tipping point" in Ismail's death. He said he would add "misplacement of the ET" as well as "high BMI" on to the death certificate.

Ismail's elder sister said her brother first fell ill on 23 March 2020. He was admitted to hospital on 26 March 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. Ismail's family was not able to be with him in intensive care because of hospital policies at the time due to the first Covid-19 lockdown.

Senior coroner for London inner south, Andrew Harris, said: "I am satisfied that 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", "high BMI" and Covid-19 pneumonia should be recorded on Ismail's death certificate.

However, he made it clear that, although the tube's positioning contributed to Ismail's death, he died from "complications of necessary medical treatment for a natural disease."