NHS trusts in England could be issued with tougher ventilator guidance after three Covid patients died following a mix-up with breathing tubes, MailOnline can reveal.
In all three cases, filters which prevent the build-up of fluid were not attached to the machines, resulting in dangerous blockages.
A coroner who probed two of the fatalities — Kishorkumar Patel, 58, and Kofi Aning, 66 — has asked watchdogs to take urgent action ‘to prevent future deaths’.
The report said that there was too much variability between machines, which amounted to an ‘extremely confusing situation’ for medics trying to operate them.
It warned that the issue was likely widespread through the NHS, and not just at the hastily-built Nightingales designed to ease Covid pressure on regular hospitals.
The coroner’s report has given watchdogs until September 1 to issue updated guidance to intensive care doctors and nurses about ventilators.
It calls for a standarised layout and colour coding across all ventilators, so staff trained to operate one specific model can use all different versions.
Experts speaking to MailOnline today backed the report but said the issue was likely ‘specific’ to the Nightingale due to the ‘extraordinary circumstances’ at the time.
Kishorkumar Patel (pictured with his son Anish in 2004) was one of three Covid patients to die at London’s makeshift Nightingale Hospital after a ventilator mix-up
Mr Patel, 58, from Sudbury, north west London, was initially admitted to Northwick Park Hospital on April 4, 2020, before he was transferred to the Nightingale Hospital in London
The Nightingale opened on April 3 last year and was one of seven temporary hospitals set up to take pressure off the NHS during the initial wave of the virus
A total of ten patients were affected by the ventilator filter mix-up at the Nightingale hospital in the ExCel Centre last April, MailOnline revealed yesterday.
A serious incident report at the time found staff failed to attach the heat and moisture exchange (HME) filters, which prevent the build-up of mucus.
WHAT WAS THE VENTILATOR ERROR?
A total of ten patients were affected by the ventilator filter mix-up at the Nightingale hospital in the ExCel Centre last April.
Three were fatal — in the cases of Kishorkumar Patel, 58, Kofi Aning, 66, and a third unnamed patient.
A serious incident report from the NHS at the time found staff failed to attach the heat and moisture exchange (HME) filters, which prevent the build-up of mucus.
It led to the breathing tubes becoming blocked and saw all patients ‘suffer harm’. They all required re-intubation.
Inquests into the deaths are scheduled for October.
In three cases it led to the breathing tubes becoming blocked and saw all patients ‘suffer harm’ and require re-intubation. All three patients eventually passed away.
It has not been determined whether the filter incidents contributed to the deaths of Mr Patel, Mr Aning and the third unnamed patient. Inquests into the deaths are scheduled for October.
Coroner Nadia Persaud said the ‘confusing’ way in which the machines vary model to model could lead to future deaths.
She ruled the classification and colour coding was ‘worthy of review, simplification, and standardisation’.
The original coroner’s report, released last month, was sent to the Royal College of Anaesthetists and the Faculty of Intensive Care Medicine.
It read: ‘In my opinion, the non-standardised colour coding used by manufacturers of these filters, the number of different types of filters with different names, the variable optimal position of the filters, and whether a wet or a dry breathing system is being used, results in an extremely confusing situation.’
The report added: ‘In my opinion there is a risk that future deaths could occur unless action is taken.
‘The concerns raised by the independent expert are not confined to the Nightingale, emergency provision hospitals, but relate equally to all intensive care settings, particularly when the intensive care provision has to be extended to other areas of the hospital.’
A serious incident report found Nightingale staff failed to attach the heat and moisture exchange (HME) filters, which prevent the build-up of mucus, in three cases. All three patients died in the following weeks but it’s not clear if the error played a role
The coroner’s report: Key findings and critical actions
- Anaesthetic machines were being used to provide ventilation to patients for long periods of time. The machines were being used for a function that they were not designed for.
- There was a lack of expertise within the clinical team working in the ICU – it was noted that non-anaesthetic ICU consultants were not familiar with the anaesthetic machines being used.
- The correct use of filters and their position within the circuit was complicated and may not have been clear to all ICU staff.
- There were multiple filers available for use with the machines and it was not immediately obvious on sight which filters were HME.
- Suctioning was undertaken by staff with limited expertise and the machines in use may not be as effective as standard ICU suction machines.
- There were different types of ventilators in place which may have contributed to potential confusion regarding what each patient needs.
- A checklist of the ventilator circuit is written and implemented at the start of every shift, to be completed by the anaesthetist and ODP to ensure correct circuit set up and humidification.
- Gain assurance that bedside nursing staff are clear on the mechanism for checking suction machines.
- Swap out anaesthetic machines for ICU ventilators with appropriate humidifiers within the circuit – nullifying the need for HME filters.
- There needs to be further discussion with NHSI/Supply chain regarding equipment for patient ventilation at NHL.
- The risk associated with using anaesthetic machines as ventilators at NHL is escalated to the hospital risk register.
Neither body has yet to officially respond to the Ms Persaud’s request, which gave them a deadline of September 1. Both declined to comment when approached by MailOnline today.
Experts have said the tragic cases were the result of an ‘extraordinary’ set of circumstances borne out of the pandemic, rather than a widespread issue.
Professor Hugh Montgomery, an intensivist at University College London who was speaking in a personal capacity, told MailOnline today: ‘I’ve not heard of this being an issue anywhere else, nor have I ever seen it on an ICU on which I have worked.
‘The cases all occurred at the Nightingale Hospital, which was set up as an extraordinary one-off structure, and generally not staffed in the same manner as ordinary “on site” ICUs, nor by “teams that routinely work together” as in such existing ICUs.
‘My instinct is thus that this was a rare event, the likelihood of which occurring was increased by the extraordinary circumstances pertaining at the time and specific to that location.’
Dr Ron Daniels, an intensive care doctor and chief executive of Sepsis UK, backed calls for ventilators used in the UK to be standardised.
He told MailOnline: ‘It’s entirely logical and appropriate to remove any opportunity for user error. Standardisation is vital and hugely important for that.
But he revealed he had never heard of a ventilator mix-up in his time on the front lines in intensive care.
Dr Daniels said that Nightingale staff were ‘treating more patients’ than they would have been used to and under intense pressure, which he described as ‘circumstances which allow error to creep in’.
He accepted that the problem could occur in other ICUs, where ‘agency staff might be moving from one intensive care unit to another’.
‘If they are using equipment they are unfamiliar with, then there’s an increased opportunity for human error.’
The Nightingale Hospital in London, which was opened by Prince Charles on April 3, was one of seven temporary hospitals opened to great fanfare at the start of the pandemic last year, along with centres in Birmingham, Manchester, Exeter, Harrogate in North Yorkshire, Bristol and Washington in Tyne and Wear.
Prior to its opening, images from inside the field hospital showed military personnel erecting cubicles and carrying equipment into the transformed centre- which was set to hold up to 4,000 Covid-19 patients.
The centre was hastily put up in less than two weeks in March, amid fears the capital’s hospitals could be overwhelmed by spiralling Covid-19 admissions.
However by May 6, 2020, the Government dashboard showed only five patients remained at the facility and just six weeks later the hospital was moved to ‘standby’ and closed its doors on May 15.
Figures later showed the temporary hospital only treated a total of 54 patients.
Efforts were then launched to re-construct a ‘scaled-down’ version of the mothballed hospital and the facility was reopened in January this year to admit non-Covid patients in order to ease the pressure in the critical care wards across the capital.
In March, medical staff at the Nightingale Hospital defended the creation of facility but admitted the complexity of coronavirus led to issues.
In a paper in the medical journal Intensive Care Medicine, the doctors disclosed 54 patients were treated for Covid between April 7 and May 7 and all those admitted were invasively ventilated at the time of admission.
In their paper the staff said that it ‘remains moot’ whether the facility was the best way of treating patients.