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| Version 1 | Version 2 |
|---|---|
| Hatfield woman died after breathing tube put in food pipe | Hatfield woman died after breathing tube put in food pipe |
| (about 10 hours later) | |
| Emma Currell had a six-year-old child and lived with kidney disease | Emma Currell had a six-year-old child and lived with kidney disease |
| 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. | 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. | 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. | 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. | 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. | 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. | 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. | An anaesthetic team was called to sedate her as her tongue had swelled and she was bleeding from the mouth. |
| Trainee anaesthetist Sabu Syed and technician Nicholas Healey both raised concerns about the tube, the inquest heard | Trainee anaesthetist Sabu Syed and technician Nicholas Healey both raised concerns about the tube, the inquest heard |
| 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." | 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. | 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. | "Dr Mukherjee was busy doing other tasks," she added. |
| "I had a look myself. Unfortunately her tongue was more swollen." | "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. | 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. | "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." | "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. | He said that both he and Dr Syed had raised concerns about the tube being in the wrong place. |
| Dr Prasun Mukherjee told Hatfield Coroners' Court he "probably did not have enough time to ask for external help" | Dr Prasun Mukherjee told Hatfield Coroners' Court he "probably did not have enough time to ask for external help" |
| Dr Mukherjee told the hearing he still detected breathing and assumed the machine readings had malfunctioned and there was a problem with the monitor. | 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. | 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." | 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. | 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. | 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. |
| 'Catastrophe' | 'Catastrophe' |
| In his narrative conclusion, Mr Danbury said the carbon dioxide readings were not acted on for a "considerable" period of time. | 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. | "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. | 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". | 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". |
| Find BBC News: East of England on Facebook, Instagram and Twitter. If you have a story suggestion email eastofenglandnews@bbc.co.uk | Find BBC News: East of England on Facebook, Instagram and Twitter. If you have a story suggestion email eastofenglandnews@bbc.co.uk |
| Related Topics | Related Topics |
| Watford | Watford |
| Hatfield | Hatfield |
| Watford General Hospital | Watford General Hospital |
| NHS | NHS |