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Misplaced tube 'contributed to UK COVID-19 child death'

A misplaced breathing tube contributed to the death of a 13-year-old boy who became the United Kingdom's first known child victim of coronavirus, a coroner has ruled.

Ismail Mohamed Abdulwahab, of Brixton, southwest London, died of acute respiratory distress syndrome (ARDS), caused by COVID-19 pneumonia, in the early hours of March 30, 2020, three days after testing positive for the coronavirus.

He had a cardiac arrest before he died.

Ismail's family members were not able to be with him when he died in King's College Hospital and were also unable to attend his funeral because they were self-isolating after some of his siblings experienced COVID-19 symptoms.

Four people wearing protective clothing, gloves and face masks lowered his coffin into a southeast London grave in April 2020.

Matt Hancock, who was the health secretary and the father of a 13-year-old child himself, said Ismail dying without a parent at his bedside "made me weep".

And King Charles, then the Prince of Wales, said in April 2020 he was "utterly heartbroken" by the teenager's plight.

Hours before Ismail's death, an endotracheal tube (ET) used to help patients breathe was found to be in the wrong position and a decision was made by a consultant in paediatric intensive care to leave it and monitor him.

The teenager did not survive the night.

Senior coroner Andrew Harris said: "I am satisfied that he would not have died when he did were it not for the tube misplacement."

He said the tube becoming displaced was "the trigger" that led to Ismail's "unexpected" cardiac arrest.

Harris said "misplaced ET" and "high BMI" should be recorded under ARDS and COVID-19 pneumonia on Ismail's death certificate.

However, he made it clear that although the tube's positioning contributed to Ismail's death, he did not find that the boy would not have died at another time had there been no misplacement.

"Ismail died from complications of necessary medical treatment for a natural disease," the coroner said.

A statement made by Ismail's eldest sister, read out in court, described him as a "kind and genuine soul".

He was admitted to hospital on March 26 2020 after experiencing fever, coughing, shortness of breath, vomiting and diarrhoea.

The next day, he was put into intensive care and tested positive for COVID-19.

His sister told the inquest a phone call was received hours before Ismail's death asking for a family member to go to see him.

"Once we arrived, we were met with the dreadful, shocking and sad news of his passing," she said.

"We are overwhelmed with grief by his passing."

Harris said the hospital was under "unprecedented pressures" from the first wave of the pandemic and that, despite "demands previously unknown" and "understandably terrified" staff, Ismail was provided with continuous intensive care.

He said he hopes the inquest will allow the family to "rebuild" their lives.