Hatfield woman died after breathing tube put in food pipe

A mother-of-one died after a breathing tube was put into her food pipe, despite staff raising concerns it was inserted incorrectly, an inquest heard.

Emma Currell, 32, had just received dialysis and was heading home to Hatfield, Hertfordshire, in an ambulance when she had a seizure.

She returned to Watford General Hospital, where the tube was inserted.

The hearing was told she went into cardiac arrest and died that night, on 5 September 2020.

Ms Currell had required dialysis for nephrotic syndrome, a kidney disease that leads to leakage of protein from the blood into the urine and a build-up of water in the body.

The inquest in Hatfield was told that while waiting in accident and emergency, Ms Currell experienced a second seizure.

An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth.

Dr Sabu Syed, who was a trainee anaesthetist, told the hearing: "I used suction to remove blood and I was able to push the tongue to the side and got a partial view."

She said she believed she inserted the tube into the trachea - the windpipe - and had asked her senior colleague Dr Prasun Mukherjee to check the position of the tube.

"Dr Mukherjee was busy doing other tasks," she added.

"I had a look myself. Unfortunately her tongue was more swollen."

Technician Nicholas Healey said he flagged his concerns when there was no carbon dioxide reading on the ventilator, which was not faulty.

"I was not confident the tube was in the right place," he added.

"A couple of doctors listened to her chest and they were confident there was a reaction."

He said that both he and Dr Syed had raised concerns about the tube being in the wrong place.

Dr Mukherjee told the hearing he still detected breathing and assumed the machine readings had malfunctioned and there was a problem with the monitor.

He said he was also concerned about the risks of removing the tube and the danger of surgery.

Asked by Graham Danbury, the deputy coroner for Hertfordshire, if it had crossed his mind to summon a more senior colleague, he said: "I probably did not have enough time to ask for external help."

He agreed he had made the wrong decision, saying that at the time they were dealing with the Covid pandemic.

The court heard the hospital had drawn up a guideline checklist for trachea procedures since Ms Currell's death and staff were due to have "no trace = wrong place" training on the warning signs of incorrect insertion.

In his narrative conclusion, Mr Danbury said the carbon dioxide readings were not acted on for a "considerable" period of time.

"It is accepted by the hospital that the tube was initially in the wrong place and Dr Mukherjee said action should have been taken sooner," he said.

After the inquest, Ms Currell's sister Lauren said the family was glad to have some "clear answers" and they hoped the hospital would "fulfil their promise" over improved procedures.

Emma Kendall, representing the family in an ongoing civil claim, said The Royal College of Anaesthetists ran its 'no trace = wrong place' campaign in 2019 "precisely so that this type of catastrophe never occurs".

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