- Kishorekumar Patel, 58, died on 26 April last year at Nightingale in London.
- He was said to be ‘physically stable’ before being transferred to the hospital
- Senior doctor says field hospital has ‘no control’ over equipment or staff
- Three covid patients had blocked breathing tubes at London Nightingale
A senior doctor at London’s NHS Nightingale Hospital has said in the investigation into the death of a Covid patient that he had ‘no control’ over equipment or staff and that the hospital did not have ‘the care we thought we needed’ .
Kishorekumar Patel, a 58-year-old London bus driver, was one of the first patients to be shifted to the flagship Nightingale, which was opened last year by the then Health Secretary Matt Hancock on April 7 for coronavirus treatment.
The father of six, who had no underlying health conditions, died 19 days later on April 26, despite being described as ‘physically stable’ before being transferred.
He was one of three patients to die at the Excel Center in Newham, east London, after staff left his intensive care ventilator without a heat and moisture exchange (HME) filter, according to a Serious Incident Report (SIR).
HME filters are placed at the end of the patient’s respiratory tract to moisten it The machine blocks the build-up of mucus and airways in the airways, which in turn can block the patient’s airway and endotracheal (ET) tube.
But a staff error, which saw them using the wrong filter in the ventilation circuit, blocked the breathing tubes in three patients and all of them ‘suffered’ and needed re-intubation.
During today’s questioning, Dr Alastair Proudfoot, chief of clinical at Nightingale in London, told coroner Nadia Persaud that the hospital “was not the care we thought was available” amid the first wave of the pandemic.
Kishorekumar Patel, 58, was one of three patients who died at Nightingale Hospital in London in April last year.
London’s Nightingale Hospital was one of seven temporary hospitals opened by then-Health Secretary Matt Hancock at the start of the pandemic last year.
Dr Proudfoot said: ‘We didn’t have the care we thought we needed. Two of the major items we had no control over were equipment and staff.
‘Ventilators and ICU nursing staff were two of the most prized possessions in the NHS.
‘Unusually we were given no ownership or understanding of what equipment we were getting and why.
‘In terms of employees, again those who came either voluntarily or were issued by their parent’s trust.
‘It was handled by NHS London – we didn’t put any ads. We invited people to come, but we had no control over who we hired.
‘It was not a homogenous group of people who had previously worked together or had met each other before.’
The hospital used two types of machines to ventilate patients, the Penlon anesthetic machine and the more complex and effective Dredger ICU ventilator, as heard in the inquiry.
But due to a lack of ICU grade ventilators, Mr Patel, who was a first degree black belt in kung fu, was put on an anesthetic machine, which is designed for short-term use only, until April 13.
Dr Proudfoot continued: ‘The anesthetic unit is not as capable as an ICU ventilator. If I was going to go raw, it’s effectively a bag of gas that goes up and down.
‘We were moving patients from the anesthetic machine to the ventilator when they became available.
‘In an ideal world, we would have been provided with 4,000 ventilators, I didn’t have that, we would have been provided with anesthetic machines.
‘Initially all we knew about Covid-19 was that it was primarily a lung disease and through an inflammatory process it turned into multiple organ failure.’
Seven days before his death, Mr Patel’s family was told that a doctor at the hospital had found that his endotracheal (ET) tube in his trachea, which provides oxygen to a patient, had a ‘wrong filter’ in his ventilator. ‘ was blocked as a result. .
A serious incident report sent to the family later described how medical staff found that their intensive care ventilator did not use heat and moisture exchange filters – resulting in no humidification of the machine.
The incident would ‘reduce the effectiveness’ of the ventilator and ‘contribute to Mr Patel’s deteriorating health on 19 April’, a letter to the family of Barts Health NHS Trust added.
Dr Nikul Patel, who traced the error inside the ventilation system of the bus driver, explained how he found that the bacterial and viral filters were incorrectly installed instead of the moisture and moisture exchange (HME) filters in the ventilators.
He said that if the right filter had been used, ‘the secretion would not have formed in such a short time’.
Dr Patel said: ‘It was noted that the filter on the patient end was a different make and model than was commonly used. The patient must have a heat and moisture exchanger, or HME, and these come in a variety of sizes and colors.
‘I noticed that the filter used was a bacterial and viral filter which was also hydrophobic.
‘This raised my suspicions because generally HME filters absorb water and therefore allow humidification of the airways.
‘A junior doctor searched the make and model of the filter on the internet and we found that the filters used were not HMEs, but only bacterial filters suggested in the packaging.
‘Then we replaced this patient and all the other filters in the ward for HME.’
The doctor noted that the wrong filter had caused an ‘excessively thick discharge’, which had blocked Mr Patel’s airway.
Asked if he had spoken to staff about the incident, he said: ‘I think we talked about it. I asked if anyone had noticed this.
‘It was unclear, people had vague thoughts and ideas about whether that filter was in use a week ago or whether it has been used now.
‘I don’t think anyone was sure what was in that filter…