Hospital Used Wrong Ventilator Filter On COVID-19 Patient Causing Cardiac Arrest: Report

A 58-year-old COVID patient's death at a hospital was "in small part" due to the hospital staff using the wrong filter on his ventilator, an inquest has found. The patient suffered a cardiac arrest and kidney decline following the filter error.

Kishorkumar Patel, a bus driver, died at the temporary hospital built in East London on April 26, 2020, BBC News reported.

Though the medical cause of death was multiple organ failure and COVID-19 pneumonitis, an East London Coroner's Court found Tuesday that Patel also suffered cardiac arrest after an incorrect filter was used in his ventilator by confused NHS staff.

According to senior coroner Nadia Persaud, the packaging used on the filters "was not clear". This resulted in the staff using a "dry filter" by mistake, leading to a cardiac arrest and a decline in kidney function, she said.

Patel is said to have shown COVID symptoms, including difficulty to breath, on March 18 last year. On April 4, he was taken to a North London hospital, where doctors diagnosed him with "severe COVID-19."

He was then moved to a temporary hospital, following which he was placed on a ventilator on April 7. His condition was largely stable for five days until he suffered a cardiac arrest and a decline in kidney function on April 12.

"This seems likely to have been due to the blocked tracheal tube, and it is likely that a dry filter had been used in error. Mr Patel died as a result of an overwhelming COVID-19 disease, but his death was in small part contributed to by a lack of a heat and moisture exchange in his ventilator circuit caused by use of an incorrect filter," Persaud told the court.

The coroner warned that the incident highlighted the packaging issue which was still a problem in hospitals today.

"All hospitals are facing issues of supply so this has become more important in the context of today. The color coding (of the filters) was confusing, the packaging was not clear in relation to what the filters were, and a junior doctor had to go to the internet to carry out research to understand which filter to use on Mr Patel later in his treatment,” she added.