A MISPLACED breathing tube contributed to the death of the UK’s first child victim of Covid, a coroner has ruled.
Ismail Mohamed Abdulwahab, 13, died of acute respiratory distress syndrome (ARDS) caused by Covid-19 pneumonia three days after testing positive for the virus.
PAUndertakers wearing PPE lower Ismail Mohamed Abdulwahab’s coffin during his funeral[/caption]
PAMourners spaced out for social distancing in April 2020[/caption]
He had a cardiac arrest before his death in the early hours of March 30, 2020.
Ismail’s devastated family were not able to be with him when he passed away at King’s College Hospital and were also unable to attend his funeral.
Several were self-isolating after some of his siblings experienced Covid symptoms.
Four people wearing protective clothing, gloves and face masks lowered his coffin into a south 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”.
And King Charles, then the Prince of Wales, said he was “utterly heartbroken” by the teenager’s plight.
Hours before Ismail’s death, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position.
A decision was made by a consultant in paediatric intensive care to leave it and monitor him but he 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, which led to him becoming the youngest person to die after contracting Covid in the UK at the time.
Mr Harris added that the “misplaced ET” and “high BMI” should be recorded under ARDS and Covid-9 pneumonia on Ismail’s 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 made 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 a fever, coughing, shortness of breath, vomiting and diarrhoea.
The next day, he was put into intensive care and tested positive for Covid-19.
‘OVERWHELMED WITH GRIEF’
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.”
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.
Asked during her evidence on Wednesday 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.
“It was a real oversight.”
I was so focused on the lungs I just didn’t see how high this tube was.
Dr Tushar Vince
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 him be 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.”
Giving evidence, Dr Khatri told the court 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.
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.