Man transferred to NHS Nightingale died from ventilator mistake

A London bus driver who died in a Nightingale Hospital was deemed “stable” before he was placed in the hands of staff who used the wrong ventilator equipment, an inquest heard.

Kishorkumar Patel, 58, was admitted to Northwick Park Hospital in Harrow after contracting Covid-19, but was later transferred to the Nightingale ExCel Centre in east London in the hands of “inexperienced” staff, where he died.

The father-of-six, who had no underlying health conditions was considered an ideal transfer to the Nightingale Hospital that was set up to treat a potential influx of patients during the pandemic, as Northwick Park dealt with a spike of Covid patients in the area.

He spent 19 days in hospital beds before his death on April 26.

The inquest has come after coroner Nadia Persaud sent a report to prevent future deaths to the Royal College of Anaesthetists, after multiple incidents of staff using the “wrong filter” occurred in at least two deaths.

She said in her report: “There was a serious incident in which the wrong filter was found to have been used within the breathing systems of the intensive care ventilator.

“It is understood that these two cases came within a cluster of similar incidents.

“No conclusion has been reached as to whether the incident with the filter contributed to the deaths.”

She explained that the concerns raised by an independent expert were “not confined to the Nightingale” but in general, intensive care settings can get confused over breathing system filters and HMEs (heat and moisture exchangers).

Dr Tariq Husain, a consultant in anaesthesiology at Northwick Park Hospital, explained that Mr Patel had to be transferred as the hospital had “five to six consultants managing the patients”.

Northwick Park Hospital was extremely busy at the time, and patients had to be transferred when possible

Northwick Park Hospital was extremely busy at the time, and patients had to be transferred when possible

The inquest was told the hospital had ordered new ventilators, bringing the total to around 30, before the pandemic as several were about to be decommissioned.

They had also started to use anaesthetic machines, which can also work as a ventilation system, among those who seemed to be more stable than the more serious cases.

Dr Husain said: “There were a group of patients who were physiologically safe. There were also a large group of patients that were unable to be transferred because they were too unsafe and there was a substantial risk they would deteriorate enroute.”

Mr Patel’s sister, Ursha Lee, who attended the hearing remotely, said the family only agreed for their loved one to be removed because they were told the hospital had no beds.

The doctor said: “We had to create capacity. If we didn’t, people would have been dying in corridors.

“It wasn’t intentional for us to not pay mind to what families wanted, as I know some families didn’t want their relatives transferred out.

“For the greater good, some patients had to be transferred out.”

He explained that patients that were “physiologically stable” were chosen to be transferred.

“The Nightingale team, over the course it existed, had an admission criteria that slightly changed throughout the pandemic.

“But any of the patients that fulfilled the criteria would be considered for transfer.”

The inquest continues, and is expected to end tomorrow.

Harrow Times | Local News