Ventilator filter error contributed to coronavirus death of father-of-six

A father-of-six who suffered multiple organ failure while ill with coronavirus died “in small part” because his ventilator was fitted with the wrong filter, an inquest has found.

London bus driver Kishorkumar Patel, 58, died primarily of “overwhelming coronavirus disease” at the temporary Nightingale Hospital in east London on April 26 last year, East London Coroner’s Court heard.

His medical cause of death was multiple organ failure and Covid-19 pneumonitis, which is inflammation of the lungs.

Senior coroner at Walthamstow Coroner’s Court Nadia Persaud said Mr Patel also suffered a cardiac arrest after an incorrect filter was used in his ventilator by confused NHS staff, and this contributed to his death.

Ms Persaud warned that without action by hospitals more deaths could come as a result of confusing colour coding and unclear packaging of the filters.

She told the court Mr Patel was married with six children, had a healthy BMI and no underlying health conditions, and he regularly practised martial arts, swimming and jogging.

Mr Patel had been a bus driver for 14 years, achieved a black belt in kung fu at the age of 55, and was studying for a law degree at the time he died.

He began suffering with coronavirus symptoms including a sore throat, fever, fatigue, loss of taste and smell, and difficulty breathing on March 18 last year, the court heard.

On April 4 he was admitted to A&E at Northwick Park Hospital in Harrow, north London, where doctors recorded he was suffering with “severe Covid-19 disease”.

The following day, his condition worsened with a heart-rate of 200 beats-per-minute, and he was transferred to the temporary Nightingale Hospital at the ExCel Centre “due to the overwhelming number of patients requiring ICU care” at Northwick Park, Ms Persaud said.

The NHS Nightingale facility at the Excel Centre, London (Jeremy Selwyn/Evening Standard/PA)
The NHS Nightingale facility at the Excel Centre, London (Jeremy Selwyn/Evening Standard/PA)

She said although Mr Patel was placed on a ventilator, his condition was largely stable from April 7 to 11, until on April 12 he suffered a cardiac arrest partly brought on by the use of the wrong filter in his ventilator.

Ms Persaud told the court: “On April 12 Mr Patel suffered a cardiac arrest and decline in his kidney function.

“This seems likely to have been due to the blocked tracheal tube, and it is likely that a dry filter had been used in error.

“Mr Patel died as a result of an overwhelming Covid-19 disease, but his death was in small part contributed to by a lack of a heat and moisture exchange in his ventilator circuit caused by use of an incorrect filter.”

Ms Persaud said it was likely Mr Patel caught Covid-19 while at work despite his employer, RATP Dev, taking “reasonable steps to protect their employees”.

The senior coroner warned that his death has highlighted packaging issues which are still a problem in hospitals today.

She said: “All hospitals are facing issues of supply so this has become more important in the context of today.

“The colour coding (of the filters) was confusing, the packaging was not clear in relation to what the filters were, and a junior doctor had to go to the internet to carry out research to understand which filter to use on Mr Patel later in his treatment.”

In her Action to Prevent Future Deaths report published on July 7 this year, Ms Persaud said there had been “a cluster of similar incidents” at the hospital but the issue was “not confined to the Nightingale”.

Ms Persaud added in the report that the “confusion over breathing system filters” is “widespread among ICU doctors and nurses”.

The coroner said Mr Patel’s family had remembered him for “his stringent example for always searching for the truth”.

She told his sister Ursha Lee and son Anish Patel who attended the inquest by video link: “I hope the inquest has helped you in your search for the truth.”