A hospital used the incorrect ventilator filter on a COVID-19 patient, resulting in cardiac arrest, according to a report.
An inquest found that a 58-year-old COVID patient’s death at a hospital was caused “in part” by hospital staff using the improper filter on his ventilator. Following the filter mistake, the patient had cardiac arrest and kidney failure.
Kishorkumar Patel, a bus driver, died on April 26, 2020, at a makeshift hospital in East London, according to BBC News.
Despite the fact that Patel died of multiple organ failure and COVID-19 pneumonitis, an East London Coroner’s Court found Tuesday that he also died of cardiac arrest after confused NHS employees used the wrong filter in his ventilator.
The packaging used on the filters, according to senior coroner Nadia Persaud, “was not transparent.” According to her, this resulted in the personnel accidentally utilizing a “dry filter,” which resulted in a cardiac arrest and a decline in renal function.
Patel is alleged to have displayed COVID symptoms, such as breathing difficulties, on March 18 of last year. He was transported to a North London hospital on April 4 and diagnosed with “severe COVID-19,” according to physicians. He was then transferred to a temporary hospital and placed on a ventilator on April 7. On April 12, he suffered a cardiac arrest and a deterioration in kidney function after a five-day period of relative stability.
“This appears to have been caused by a blocked tracheal tube, and it’s likely that a dry filter was employed inadvertently.” Mr Patel died as a result of an overpowering COVID-19 condition, however a lack of heat and moisture exchange in his ventilator circuit caused by the use of an improper filter contributed to his death in a tiny way,” Persaud told the court.
The coroner noted that the incident brought attention to a packaging problem that still exists in hospitals today.
“Since all hospitals are experiencing supply challenges, this has become even more critical in today’s environment.” “The color coding (of the filters) was perplexing, the package was unclear as to what the filters were, and a junior doctor had to conduct research on the internet to figure out which filter to use on Mr Patel later in his treatment,” she continued.