A coroner has found that a misplaced medical tube contributed to the death of the first child in the UK to die after contracting Covid.
Ismail Mohamed Abdulwaab, 13, from Brixton, South London, died of acute respiratory distress syndrome due to 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 sparked widespread concern about the potentially fatal impact of Covid on children. The public shock over his death escalated when it emerged that his immediate family, including six siblings, could not attend his funeral as 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 pediatric intensive care decided to leave and monitor her.
Delivering his verdict on Thursday, Senior Coroner Andrew Harris said: “I am satisfied that he [Ismail] Had the tube not been misplaced, he would not have died.”
On Wednesday, the inquest at the London Inner South London Coroner’s Court heard evidence from Dr Tushar Vince, a consultant in pediatric intensive care at King’s College Hospital, who treated Ismail following his intubation on 29 March.
Asked by Harris whether it would be appropriate to put ET’s condition on the death certificate as one of the causes, Dr Vince said: “I think it would be appropriate to consider, yes.”
She said: “I was so focused on the lungs that I didn’t see how high up that tube was and I’m sorry I didn’t see it.”
He added: “It was a real oversight that I didn’t see the tip of this tube.”
The court heard that another child therapist, Anuj Khatri, told Vince at around 9.30am that the tube was too high, but after a conversation about the risks of whether or not to move ET, he decided not to do it again .
The court heard Ismail was “reforming” at the time.
During his testimony, Khatri told the court that he did not agree with his colleague’s decision not to carry Ismail on his back so that the tube could be adjusted.
He said he believed the position was “urgent” because a highly placed tube could be dislodged which was “potentially life-threatening and paralyzing” for patients taking muscle relaxants.
Vince told the court that a dislodged tube should not “easily” lead to cardiac arrest in previously fit and healthy children.
“So was he really more sick than we thought?” He asked.
In Wednesday’s tentative opinion, Harris said “condemnation” cannot be applied to the incident.