Inquest hears evidence of mistakes in Nightingale patients’ care

An inquest into the death of a London bus driver at London’s Nightingale Hospital during the first wave of coronavirus has heard evidence about equipment mistakes which may have harmed patients.

Kishorkumar Patel, aged 58, was one of the first patients to be admitted to the field hospital at London’s Excel Conference Centre in April last year.

An inquest on Wednesday at East London Coroner’s Court was told doctors and nurses were forced to work “leanly” because of limited staff and ventilators to help patients breathe.

Mr Patel is one of 10 patients who had the wrong filter used on the ventilator machines which it is thought triggered a cardiac arrest in Mr Patel, a father of six.

A serious incident report identified 10 patients were affected by the use of the wrong filter, with three said to have been harmed as a result. Mr Patel was identified as the third patient.

The Nightingale Hospitals were designed to alleviate pressure on the NHS in the event of tens of thousands of patients needing to be ventilated. In the end there were barely used due to a lack of staff and fewer serious Covid cases than predicted. At its height the Excel Centre hospital looked after just 54 patients.

The inquest heard the problem may have been caused by confusion among staff because the Nightingale Hospital was using blue filters instead of the more typical green filters used by the NHS.

Mr Patel was described as a stable patient when he was transferred to the Nightingale Hospital from Northwick Park Hospital in Harrow, north west London.

But he deteriorated over 19 days he spent on ventilators and died on April 26.

The inquest heard he suffered a one-minute cardiac arrest on 12 April which may have been due to a blocked tube caused by hard secretions linked to the use of a dry filter on the ventilator.

A doctor working at the hospital discovered the error and changed the filter to a heat and moisture exchanger that would allow the air coming into Mr Patel’s lungs to be humidified.

Evidence presented at the inquest found his condition worsened after this date leading to problems with his kidneys.

Professor Jerry Nolan, who provided an independent expert opinion on his care, found Mr Patel was previously healthy with no underlying conditions.

He gave the cause of death as multi-organ failure amid "overwhelming effect of the Covid-19 disease".

Prof Nolan said: "In my opinion, there was no failure of clinical care that contributed to his death.

"If a dry ventilator system was being used at Nightingale Hospital the failure, to use a humidified filter did contribute to the blockage of the tracheal tube and this did contribute to the cardiac arrest.

"However, in my opinion, this event did not have an impact on the ultimate outcome of this case.

"My finding on the balance of probabilities is that the wrong filter used did likely cause the blocked tube and that a short, one-minute long, cardiac arrest resulted from this.”

He said this was a “contributing factor” to the death adding: “It is possible that it just accelerated what would have happened to Mr Patel’s kidneys. I don’t think it was causal, but I think the Covid disease was sadly what took his life."

Coroner Nadia Persaud said she deliver her findings after a second inquest into the death of another patient at the Nightingale Hospital later this week.

She has already filed a prevention of future deaths report to the Royal College of Anaesthetists following the ‘wrong filter’ incidents.

She said: "I will read out my summary findings and conclusions in both inquests next Tuesday.

"I will not be writing another report to prevent future deaths but I will continue to review this matter. I do not think there is any other evidence that I have heard during this inquest that requires another report to be written."

The inquests into both cases are due to conclude at East London Coroner’s Court on Tuesday October 12.

Additional reporting by agencies