A misplaced medical tube may have contributed to the death of the first child in the UK to die after contracting Covid, a review of the case heard on Tuesday.
Thirteen-year-old Ismail Mohamed Abdulwahab’s death on 30 March 2020 at King’s College hospital in London prompted widespread shock, which was compounded when it emerged that his immediate family, including six siblings, could not attend his funeral because of Covid lockdown restrictions.
At a pre-inquest review into the case, heard over a video call, senior coroner for inner south London, Andrew Harris, expressed his condolences to Ismail’s family. Two of his older sisters were on the call. “It is particularly poignant losing a child,” Harris told the hearing.
Harris said the inquest will explore whether a misplaced endotracheal (ET) tube used to provide Ismail with more oxygen during his treatment was a factor in his death.
In a summary of the incident presented at the hearing, Harris said the tube was noted to be in a high position the evening before Ismail’s death after he had been turned to his front. A decision was made to “advance the ET” the following morning when more staff would be available, Harris said.
Ismail, who lived in Brixton, south London died that day. The medical cause of death was given as “acute respiratory distress syndrome”, the hearing was told.
Harris said when the inquest begins it will ask “why was the ET tube not repositioned earlier”. He added: “What contribution did the failure to detect the misplaced ET tube make to his death? What lessons were learnt and have any systems changed?”
He revealed that Ismail’s death prompted an internal inquiry at King’s College hospital. Harris said: “A serious incident report I understand was launched as the cardiac arrest, in time terms, appear to be associated with a presumed dislodged or obstructed ET tube.”
The inquest will hear evidence from the consultant who conducted that investigation as well as doctors and nurses who treated Ismail.
Harris said: “The family and those who will have known Ismail and will have been deeply traumatised by his unexpected death. And of course, doctors [and] nurses were working in exceptionally difficult times. And we will have to understand that as we take the evidence.”
The hearing was told that Ismail was admitted to hospital on 27 March after suffering four days of fever and cough, two days of shortness of breath and one day of diarrhoea and vomiting.
Harris said the inquest would also consider “Why did Ismail succumb to Covid as a child? Was he especially vulnerable? Was the infection particularly virulent? This is relevant because child deaths from Covid are pretty unusual. We would like to understand a bit about that.”
A date for the inquest, which is due to take a day and a half to complete, has yet to be scheduled.