Staff at London’s Nightingale Hospital contributed to the death of a Covid patient, 58, when they used the wrong filter in his ventilator, inquest hears

  • Kishorkumar Patel, 58, passed away on April 26 last year at London’s Nightingale 
  • He was described as ‘physiologically stable’ before he transferred to hospital
  • Inquest found death was caused ‘in small part’ due to error with ventilator filter 
  • Three Covid patients at the London Nightingale had blocked breathing tubes 

A coronavirus patient at London’s Nightingale Hospital died ‘in small part’ due to staff using an incorrect filter in his ventilator, an inquest has heard. 

London bus driver Kishorkumar Patel, 58, was one of the first patients to be transferred to the flagship Nightingale, for coronavirus treatment on April 7 last year after experiencing shortness of breath, coughing and fatigue. 

Despite being described as ‘physiologically stable’ before he was transferred, the father-of-six, who had no underlying health conditions, died 19 days after he was admitted to the medical facility on April 26. 

He was one of three patients to die at the ExCel Centre in Newham, East London, after staff mistakenly used anti-bacterial HEPA filters in the ventilators instead of humidity and moisture exchange (HME) filters.

The error, which was found in the ventilators of ten patients, caused Mr Patel’s breathing tube to become clogged with mucus, East London Coroner’s Court heard. 

Today, an inquest found the London bus driver, from Sudbury, north west London, who suffered multiple organ failure while ill with coronavirus, died ‘in small part’ because his ventilator was fitted with the wrong filter.

Senior coroner at Walthamstow Coroner’s Court Nadia Persaud said Mr Patel also suffered a cardiac arrest after the incorrect filter was used in his ventilator by confused NHS staff, and this contributed to his death.   

Ms Persaud said the mistake may have occurred because HEPA and HME filters are similar in colour and appearance. 

Kishorkumar Patel, 58,  was one of three patients to die at the London’s Nightingale Hospital  after staff mistakenly used anti-bacterial HEPA filters in the ventilators instead of humidity and moisture exchange (HME) filters

The London bus driver, who achieved a first-degree black belt in Kung Fu at the age of 55, was one of the first patients to be transferred to the flagship Nightingale, for coronavirus treatment on April 7 last year

She warned that without action by hospitals more deaths could come as a result of confusing colour coding and unclear packaging, the inquest heard. 

Mr Patel, who achieved a first-degree black belt in Kung Fu at the age of 55, had been a bus driver for 14 years and was studying for a law degree at the time of his death.  

He began suffering with coronavirus symptoms including a sore throat, fever, fatigue, loss of taste and smell, and difficulty breathing on March 18 last year, the court heard.

Seven days before his death, Mr Patel’s family were told a doctor at the hospital had discovered that the ET tube in his windpipe, which provides oxygen to a patient, was blocked as a result of an incorrect filter in his ventilator.

Ms Persaud said although Mr Patel was placed on a ventilator, his condition was largely stable from April 7 to 11, until on April 12 he suffered a cardiac arrest partly brought on by the use of the wrong filter in his ventilator.   

The coroner said: ‘On April 12 Mr Patel suffered a cardiac arrest and decline in his kidney function.

‘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.

 ‘Whilst Covid-19 is the overwhelming cause of Mr Patel’s death, the cardiac arrest and renal failure cause by the blocked tube was a factor.

‘His death was in small part contributed to by a lack of HME filter in a wet ventilator circuit, caused by the use of an incorrect filter.’ 

Ms Persaud said it was likely Mr Patel caught Covid-19 while at work despite his employer, RATP Dev, taking ‘reasonable steps to protect their employees’.

The senior coroner warned that Mr Patel’s death has highlighted packaging issues which are still a problem in hospitals today.

She said: ‘All hospitals are facing issues of supply so this has become more important in the context of today.

‘The colour 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.’     

The coroner also paid tribute to Mr Patel’s son Anish and his sister Ursha Lee, adding:’I have been amazed by Anish Patel and Ursha Lee,

‘They were trying to reach for the truth always with professionalism and dignity.

‘I hope this inquest has helped them in their search for the truth.’ 


Mr Patel, who achieved a first-degree black belt in Kung Fu at the age of 55, had been a bus driver for 14 years

Last week a senior doctor at the Nightingale hospital told the inquest that he had ‘no control’ over equipment or staff and the hospital did not have ‘the systems of care we thought we needed’.      

Dr Alastair Proudfoot, the clinical lead at London’s Nightingale, told Ms Persaud the hospital did not have ‘the systems of care we thought we needed’ amid the first wave of the pandemic.  

The doctor said: ‘We didn’t have the systems of care we thought we needed. Two of the very key items that we had no control over were equipment and staffing. 

‘Ventilators and ICU nursing staff were two of the most prized commodities across the NHS.

What are Heat and Moisture Exchange (HME) filters?

Heat and moisture exchangers (HME) can be placed at the patient’s end of the breathing system

In normal breathing, air is filtered, warmed and moistened by the nose and the upper airway.

However when endotracheal intubation – a procedure in which a tube is inserted through the mouth into the trachea – is performed on a patient this can result in an increased build up of mucus secretions.

This can increase the risk of infections and cause blockages in the breathing tube.

In order to combat this a heat and moisture exchangers (HME) can be placed at the patient’s end of the breathing system.  

The filters humidify the airway in circuits.   

Lack of any humidification in the circuit will increase likelihood of secretions becoming thickened – blocking the patient’s airways and ET tube.  

Anti-viral filters will also be used to  prevent contamination between patient and the ventilator machine.    

‘Unusually we were not given any ownership or understanding of what equipment we were receiving and why.

‘In terms of the staff, again the people that came either volunteered or were released by their parent trust.

‘That was controlled by NHS London – we did not put out an advert. We invited people to come and but we had no control over who we employed.

‘It was not a homogenous group of people who had worked together before or had even met each other before.’     

The hospital used two types of machines for ventilating patients, Penlon anaesthetic machines and the more complex and effective Draeger ICU ventilators, the inquest heard.

But due to a shortage of the ICU grade ventilators, Mr Patel was placed on an anaesthetic machine, which are only designed for short-term use, until April 13. 

Dr Proudfoot continued: ‘The anaesthetic unit is not as capable as an ICU ventilator. If I was going to be crude, it is effectively a bag of gas that goes up and down.

‘We were moving patients from an anaesthetic machine to a ventilator when they became available.

‘In an ideal world, we would have been provided with 4,000 ventilators, I didn’t have that, we were provided with anaesthetic machines.

‘All we knew about Covid-19 at the beginning was it was primarily a disease of the lungs and through an inflammatory process it progressed to multiple organ failure.’   

A Serious Incident Report sent to the family later described how medical staff discovered heat and moisture exchange filters had not been used in his intensive care ventilator – resulting in a lack of any humidification in the machine.

The incident would have ‘reduced effectiveness’ of the ventilator and ‘contributed to Mr Patel’s deterioration on April 19’, a letter to the family from Barts Health NHS Trust also added. 

Dr Nikul Patel, who discovered the error inside the bus driver’s ventilation system, told the inquest how he found the ventilators had incorrectly been fitted with bacterial and viral filters, rather than humidity and moisture exchange (HME) filters.

He said had the correct filters been used ‘the secretions would not have built up in such a short space of time.’    

The doctor also noted that the incorrect filters had resulted in ‘excessively thick secretions’ that led to a blockage in Mr Patel’s airways.  

When asked if he had spoken to staff about the incident, he said: ‘I think we did talk about it. I asked if anyone had noticed it.

‘It was unclear, people had unclear thoughts and views about whether that filter was in use a week ago or whether it’s just been used. 

‘I don’t think anyone was sure whether that filter had been an ongoing issue or whether it had been an issue in the past 24 hours.’        

Mr Patel was initially admitted to Northwick Park Hospital in north west London, on April 4, 2020, after experiencing shortness of breath, loss of smell, coughing and fatigue. 

But he was soon transferred to the Nightingale Hospital due to the onslaught of Covid patients in April 2020.  

During his stay at the Nightingale, Mr Patel was put on a ventilator and his family would receive daily calls from a telephone operator at the Nightingale about his health. 

However on the evening of April 18, a doctor at the hospital discovered Mr Patel’s ET tube had become blocked with secretions due to an incorrect filter in his ventilator circuit.     

Mr Patel’s sister Ursha Lee and her family were called the following day and told the wrong filter had been used in Mr Patel’s breathing machine. The member of staff apologised for the incident and said a letter would be issued.  

However on April 26, Mr Patel’s 23-year-old son Anish received a call telling him his father was dying and that he should go to the Nightingale as soon as he could to say his goodbye.    

This year Mr Patel’s sister Ursha Lee, from Wembley, described how the temporary hospital, which was the first of the Nightingale hospitals to open, was not equipped to meet the demands of the pandemic

 Mr Patel was described as ‘physiologically stable’ before he was transferred to the field hospital. Pictured: Mr Patel with his children Sarita, Kiran, Zoe, Aakash, Shane and Anish

Ms Lee described her brother (pictured with his son Anish in 2004) as a simple and gentle man who had a humble soul

Key findings and critical actions required from the Serious Incident Report

Key findings: 

  • Anaesthetic machines were being used to provide ventilation to patients for long periods of time. The machines were being used for a function that they were not designed for.
  • There was a lack of expertise within the clinical team working in the ICU  – it was noted that non-anaesthetic ICU consultants were not familiar with the anaesthetic machines being used.
  • The correct use of filters and their position within the circuit was complicated and may not have been clear to all ICU staff.
  • There were multiple filers available for use with the machines and it was not immediately obvious on sight which filters were HME. 
  • Suctioning was undertaken by staff with limited expertise and the machines in use may not be as effective as standard ICU suction machines.
  • There were different types of ventilators in place which may have contributed to potential confusion regarding what each patient needs.

Recommendations:  

  • A checklist of the ventilator circuit is written and implemented at the start of every shift, to be completed by the anaesthetist and ODP to ensure correct circuit set up and humidification. 
  • Gain assurance that bedside nursing staff are clear on the mechanism for checking suction machines. 
  • Swap out anaesthetic machines for ICU ventilators with appropriate humidifiers within the circuit – nullifying the need for HME filters.
  • There needs to be further discussion with NHSI/Supply chain regarding equipment for patient ventilation at NHL.
  • The risk associated with using anaesthetic machines as ventilators at NHL is escalated to the hospital risk register.  

A month later, Barts Health Trust sent the family a Serious Incident Report that confirmed that ten ventilated patients had been identified as not having heat & moisture exchange (HME) filters within their ventilator circuits – with harm recorded for three of these patients.

The report said Mr Patel required re-intubation after his ET tube was found to be blocked.

It went on to suggest a number of reasons that could have led to the error, including a ‘lack of expertise within the clinical team working in the ICU’ and ‘potential confusion regarding what each patient needs’ due to the different types of ventilators in place.

The report said there were ‘multiple, potentially confusing disposable filters’ available for staff and it would not have been ‘immediately obvious on sight which filters are HME’.

It added the correct use of filters and their position within the circuit was ‘complicated’ and may not have been clear to all ICU employees before going on to state that suctioning was undertaken by staff with ‘limited expertise’.

The report also said that ventilation was being provided to the majority of patients using anaesthetic machines, which are designed to provide short term ventilation in the operating theatre under the use and supervision of an anaesthetist and operating department practitioner (ODP).

When used in the ICU setting these machines can create a ‘high risk scenario’, with the use of filters within the machines being one of them, according to the report. 

Mr Patel’s son Anish was also sent a letter of apology from Barts Health Trust which said the filter error had ‘reduced effectiveness of the circuit’ and ‘contributed to his father’s deterioration on 19th April’.

A section of the letter read: ‘We discovered that an issue had occurred with the filter in the breathing circuit that was providing ventilation to your father. The wrong filter had been placed in the circuit and as a result the circuit was not functioning as effectively as it could be.

‘We feel that the reduced effectiveness of the circuit and contributed to his deterioration on 19th April; it is very difficult to say if this event contributed to his sad death.’

In August, Ms Lee described how the temporary hospital, which was the first of the Nightingale hospitals to open, was not equipped to meet the demands of the pandemic.

She told MailOnline: ‘It was a fast train going at high speed, but it didn’t have a driver. 

In August, Ms Lee described how the temporary hospital, which was the first of the Nightingale hospitals to open, was not equipped to meet the demands of the pandemic.

She told MailOnline: ‘It was a fast train going at high speed, but it didn’t have a driver. 

‘It wasn’t equipped with sufficient equipment and staff lacked expertise. It was a catastrophe.

‘I also don’t feel my brother should have been transferred there in the first place. ‘    

The Serious Incident Report said ten ventilated patients were identified as not having HME filters within their circuits. It went on to say the ET tube of Mr Patel (identified as patient 3) was found to be blocked and that he required re-intubation

The report sent from the health trust to Mr Patel’s family said there was a lack of expertise within the clinical team working in the ICU and the correct use of filer and their positions within the circuit was ‘complicated’ and may not have been clear to all staff

The report also said that ventilation was being provided to the majority of patients using anaesthetic machines – which are designed to provide short term ventilation in the operating theatre under the use and supervision of an anaesthetist

The report also said that ventilation was being provided to the majority of patients using anaesthetic machines – which are designed to provide short term ventilation in the operating theatre under the use and supervision of an anaesthetist

The Nightingale Hospital in London, which was opened by Prince Charles on April 3, was one of seven temporary hospitals opened to great fanfare at the start of the pandemic last year

The field hospital, which shut its doors on May 15, was set to hold up to 4,000 Covid-19 patients

Barts Health trust said the incident would have ‘reduced effectiveness’ of the ventilator and ‘contributed to Mr Patel’s deterioration on April 19’

The Nightingale Hospital in London, which was opened by Prince Charles on April 3, was one of seven temporary hospitals opened to great fanfare at the start of the pandemic last year, along with centres in Birmingham, Manchester, Exeter, Harrogate in North Yorkshire, Bristol and Washington in Tyne and Wear.

Prior to its opening, images from inside the field hospital showed military personnel erecting cubicles and carrying equipment into the transformed centre- which was set to hold up to 4,000 Covid-19 patients. 

The centre was hastily put up in less than two weeks in March, amid fears the capital’s hospitals could be overwhelmed by spiralling Covid-19 admissions.

However by May 6, 2020, the Government dashboard showed only five patients remained at the facility and just six weeks later the hospital was moved to ‘standby’ and closed its doors on May 15.  

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