An inquest heard that despite staff raising concerns that the breathing tube was inserted incorrectly, a mother-of-one died after it was placed in her food pipe.
After receiving dialysis, 32-year-old Emma Currell was on her way home to Hatfield, Hertfordshire, in an ambulance when she suffered a seizure.
She went back to the hospital where the tube was put in, Watford General Hospital.
She suffered a cardiac arrest that evening, September 5, 2020, and passed away, it was reported to the hearing.
Due to nephrotic syndrome, a kidney disease that causes water retention in the body and protein leakage into the urine, Ms. Currell needed dialysis.
Ms. Currell had a second seizure while waiting in accident and emergency, it was reported to the Hatfield inquest.
She had a swollen tongue and was bleeding from the mouth, so an anaesthetic team was called to tranquilize her.
A trainee anesthetist named Dr. Sabu Syed testified at the hearing that he had used suction to remove blood and that he had been able to push the tongue to one side to get a partial view. ".
She claimed to have placed the tube in the trachea, or windpipe, and she had asked her senior colleague Dr. Prasun Mukherjee to verify this.
She continued, "Dr. Mukherjee was busy with other tasks.
"I looked at it myself. Sadly, her tongue was even more enlarged. ".
When the ventilator, which was not broken, showed no carbon dioxide reading, technician Nicholas Healey said he raised concerns.
He continued, "I wasn't sure the tube was in the right spot.
"Several doctors examined her chest and were certain they heard a reaction. ".
He claimed that he and Dr. Syed had voiced their concerns regarding the placement of the tube.
Dr. Mukherjee testified at the hearing that he could still hear breathing and that he believed the machine readings were inaccurate and the monitor was at fault.
He claimed that the risks of removing the tube and the danger of surgery also worried him.
When asked if he had considered calling a more senior colleague, Deputy Coroner for Hertfordshire Graham Danbury replied, "I probably did not have enough time to ask for external help. ".
He acknowledged that he had made a mistake, explaining that at the time, they were battling the Covid pandemic.
Since Ms. Currell's passing, the hospital reportedly developed a checklist of best practices for trachea procedures, and staff members are soon to receive "no trace = wrong place" training on the warning signs of improper insertion.
Mr. Danbury stated at the end of his narrative that "considerable" time had passed before any action was taken regarding the carbon dioxide readings.
The hospital acknowledges that the tube was initially placed incorrectly, and according to Dr. Mukherjee, action ought to have been taken sooner.
Ms. Currell's sister Lauren stated following the inquest that the family was relieved to have some "clear answers" and that they hoped the hospital would "fulfill their promise" regarding improved practices.
The Royal College of Anaesthetists ran its "no trace = wrong place" campaign in 2019 "exactly so that this type of catastrophe never occurs," according to Emma Kendall, who is representing the family in an ongoing civil lawsuit.
