A mother-of-one passed away after a breathing tube was inserted improperly into her food pipe, despite staff raising concerns about it, an inquest heard.
After finishing her dialysis, 32-year-old Emma Currell was riding in an ambulance back to Hatfield, Hertfordshire, when she suffered a seizure.
She went back to Watford General Hospital to have the tube put in.
The hearing was informed that on September 5, 2020, she suffered a cardiac arrest and passed away that evening.
Due to her kidney disease, nephrotic syndrome, which causes water retention and protein leakage into the urine, Ms. Currell needed dialysis.
According to testimony given at the inquest in Hatfield, Ms. Currell had a second seizure while she was in accident and emergency.
She was bleeding from the mouth and needed to be sedated, so an anesthesia team was called.
The hearing's witness, Dr. Sabu Syed, a student anesthetist, stated: "I used suction to remove blood and was able to push the tongue to the side and got a partial view. ".
She stated that she thought she had successfully inserted the tube into the trachea, or windpipe, and that she had asked her senior colleague Dr. Prasun Mukherjee to confirm this.
Dr. Mukherjee was preoccupied with other tasks, she continued.
"I looked myself. Her tongue was unfortunately more enlarged. ".
When there was no carbon dioxide reading on the ventilator, which was not broken, technician Nicholas Healey said he raised his concerns.
I wasn't sure the tube was in the proper spot, he continued.
"Several doctors examined her and were certain they heard a reaction when they listened to her chest. ".
He claimed that he and Dr. Syed had voiced their concerns about the tube's improper placement.
Dr. Mukherjee testified at the hearing that he could still hear breathing and that he believed that the monitor's malfunctioned and the machine readings were inaccurate.
The risks of removing the tube and the danger of surgery, he claimed, also worried him.
When Graham Danbury, the deputy coroner for Hertfordshire, questioned him about whether the thought had ever occurred to him to call in a more senior colleague, he responded, "I probably did not have enough time to ask for external help. ".
He acknowledged that his choice had been poor, explaining that the Covid pandemic was in full swing at the time.
The hospital had created a checklist of best practices for trachea procedures in the wake of Ms. Currell's death, the court was informed, and staff members would soon receive training on the "no trace = wrong place" warning signs.
The carbon dioxide readings were not taken seriously for a "considerable" amount of time, according to Mr. Danbury's narrative conclusion.
The tube was initially placed in the incorrect location, which was acknowledged by the hospital, according to Dr. Mukherjee, who claimed that action should have been taken sooner.
Lauren Currell, Ms. Currell's sister, said the family was relieved to have some "clear answers" following the inquest and expressed hope that the hospital would "fulfill their promise" regarding improved practices.
The Royal College of Anaesthetists' "no trace = wrong place" campaign was launched in 2019, according to Emma Kendall, who is representing the family in an ongoing civil lawsuit, "exactly so that this type of catastrophe never occurs."