An investigation into the death of a London bus driver at London’s Nightingale Hospital during the first wave of the coronavirus has found evidence about equipment mistakes that could have harmed patients.
Kishorekumar Patel, 58, was one of the first patients to be admitted to the field hospital at the Excel Conference Center in London in April last year.
An inquiry on Wednesday at the East London Coroner’s Court was told that doctors and nurses were forced to work “lean” to help patients breathe due to limited staffing and ventilators.
Mr Patel is one of 10 patients who had the wrong filter used on ventilator machines which is believed to have caused cardiac arrest in Mr Patel, father of six children.
A serious incident report was identified that 10 patients were affected by the use of the wrong filter, resulting in the loss of three. Mr Patel was identified as the third patient.
Nightingale hospitals were designed to ease the pressure on the NHS at a time when thousands of patients need to be ventilated. In the end it was barely used due to shortage of staff and less severe COVID cases than anticipated. At its peak, the Excel Center Hospital looked after only 54 patients.
The investigation heard that the problem may have been caused by confusion among staff as Nightingale Hospital was using a blue filter instead of the more typical green filter used by the NHS.
Mr Patel was described as a stable patient when he was transferred from Northwick Park Hospital to Nightingale Hospital in Harrow, north west London.
But his health deteriorated in 19 days spent on ventilator and he died on 26 April.
The interrogation heard that he suffered a one-minute cardiac arrest on April 12, which may have been due to a blocked tube due to hard secretions associated with the use of dry filters on the ventilator.
A doctor working at the hospital discovered the error and changed the filter to a heat and moisture exchanger to moisten the air entering Mr Patel’s lungs.
The evidence presented during the interrogation found that after this date his condition worsened, leading to problems in his kidney.
Professor Jerry Nolan, who provided an independent expert opinion on his care, found that Mr Patel was previously healthy with no underlying conditions.
He cited the cause of death as multi-organ failure amidst the “huge impact of the Covid-19 disease”.
Prof Nolan said: “In my opinion, there was no failure in clinical care that contributed to his death.
“If a dry ventilator system was being used at Nightingale Hospital, failure to use a humidified filter contributed to blockage of the tracheal tube and this contributed to cardiac arrest.
“However, in my opinion, this incident had no effect on the final outcome of this case.
“My finding on the balance of possibilities is that the wrong filter used probably caused a blocked tube and resulted in a short, one minute long, cardiac arrest.”
He said it was a “contributing factor” to the death: “It is possible that this may have happened to Mr. Patel’s kidney. I don’t think it was the cause, but I think it was the covid disease that caused his death.” took his life.”
Coroner Nadia Persaud said she gives her findings after a second investigation into the death of another patient at Nightingale Hospital later this week.
It has already filed a prevention report of future deaths to the Royal College of Anesthetists following incidents of ‘misfiltered’.
He said: “I will read my summary findings and conclusions in both inquiries next Tuesday.
“I will not write another report to prevent future deaths but I will continue to review the matter. I do not think I have heard any other evidence during this investigation that requires writing another report. “
The investigation in both cases is due to conclude on Tuesday 12 October at the East London Coroner’s Court.
Additional reporting by agencies
Credit: www.independent.co.uk /