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Young mother died after breathing tube wrongly positioned.


A young mother died after a breathing tube was put into her food pipe, even though staff warned that it was inserted incorrectly, an inquest heard.

Emma Currell, 32, had just received dialysis and was heading home to Hatfield, Hertfordshire, in an ambulance when she had a seizure.

She returned to Watford General Hospital where the tube was inserted but the inquest was told she went into cardiac arrest and died that night, on 5 September 2020.

Ms Currell had required dialysis for nephrotic syndrome, a kidney disease that leads to leakage of protein from the blood into the urine and a build-up of water in the body.

The inquest in Hatfield was told that while waiting in accident and emergency, Ms Currell experienced a second seizure.

An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth.

A trainee anaesthetist, Dr Sabu Syed,  told the hearing: "I used suction to remove blood and I was able to push the tongue to the side and got a partial view."

She said she believed she inserted the tube into the trachea - the windpipe - and had asked her senior colleague Dr Prasun Mukherjee to check the position of the tube.

She added: "Dr Mukherjee was busy doing other tasks. I had a look myself. Unfortunately her tongue was more swollen."

Technician, Nicholas Healey, said he voiced his concerns when there was no carbon dioxide reading on the ventilator, which was not faulty.

He said: "I was not confident the tube was in the right place. A couple of doctors listened to her chest and they were confident there was a reaction."

He said that both he and Dr Syed had raised concerns about the tube being in the wrong place.

Dr Mukherjee told the hearing he still detected breathing and assumed the machine readings had malfunctioned and there was a problem with the monitor.

He said he was also concerned about the risks of removing the tube and the danger of surgery.

The deputy coroner for Hertfordshire, Graham Danbury asked Dr Mukherjee if it had crossed his mind to summon a more senior colleague but the doctor replied: "I probably did not have enough time to ask for external help."

He agreed he had made the wrong decision, saying that at the time they were dealing with the Covid pandemic.

The court heard that, since Ms Currell's death, the hospital had drawn up a guideline checklist for trachea procedures and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion.

In his narrative conclusion, Mr Danbury said the carbon dioxide readings were not acted on for a "considerable" period of time.

He said: "It is accepted by the hospital that the tube was initially in the wrong place and Dr Mukherjee said action should have been taken sooner."

After the inquest, Ms Currell's sister, Lauren, said the family was glad to have some “clear answers” and they hoped the hospital would fulfil its promises over improved procedures.