A young mum from Hatfield died after a trainee doctor accidentally placed a breathing tube into her food pipe, an inquest heard.
The tube was meant to be inserted into the trachea, or windpipe, to facilitate breathing; however, it was erroneously placed in the oesophagus, or food pipe – leading to her death.
Emma Currell, 32, suffered a cardiac arrest and died on September 5, 2020.
She was being transported home to Hatfield, Hertfordshire, in an ambulance after receiving dialysis treatment when she experienced a seizure. Currell suffered from nephrotic syndrome, a kidney disease that results in the leakage of protein from the blood into the urine and the accumulation of water in the body.
Following her dialysis treatment, Currell suffered a seizure while in transit and was immediately taken back to Watford General Hospital. During her wait in A&E, the mother of one experienced a second seizure, Hatfield Coroners’ Court was told.
Media reports quoted trainee anaesthetist Dr Sabu Syed as telling the hearing, “Initially the tongue was incredibly swollen and a lot of blood was coming from the mouth. I used suction to remove blood and I was able to push the tongue to the side and got a partial view.”
Syed believed she had inserted the tube into the trachea, but later discovered it was in fact placed in the oesophagus. She requested a senior colleague, Dr Prasun Mukherjee, to verify the tube’s positioning. However, he was occupied with other duties at the time, so Syed assessed the tube’s placement on her own.
“Unfortunately, her tongue was more swollen,” she said, about the patient.
Mukherjee told the hearing: “I had confidence in my colleague that the tube was appropriately placed.”
Deputy coroner for Hertfordshire, Graham Danbury, asked Mukherjee, “Did you, with greater experience, consider that you should have done the administration?”
He said was “difficult”, as younger colleagues need to acquire additional experience.
“Retrospectively and with hindsight, we know the tube was in the wrong place.”
After Currell’s death, Dr Thomas Sanbach conducted an in-depth investigation and said a guideline checklist had been developed for tracheal procedures carried out outside the operating theatre at Watford Hospital.
In addition, staff will receive simulation training.
