Mr Kishorkumar Patel and Mr Kofi Aning · Prevention of Future Deaths report

On the 6 May 2020, I commenced an investigation into the deaths of Mr Kishorkumar Patel and Mr Kofi Aning. The investigation is ongoing and the inquest hearings are listed to be heard in October 2021. It is my view that the concern that has been brought to my attention, is a concern that requires addressing at the earliest possible stage. I do not consider that it is appropriate to await the conclusion of the Inquest hearings.

Mr Patel and Mr Aning were both treated at the Nightingale Hospital in London in April 2021. In both cases there was a serious incident in which the wrong filter was found to have been used within the breathing systems of their intensive care ventilator. It is understood that these two cases came within a cluster of similar incidents. No conclusion has been reached as to whether the incident with the filter contributed to the deaths. The question of causation will be considered at the Inquest hearings. The question of causation is not determinative of the making of a Preventing Future Deaths Report.

An independent expert has advised:

In my opinion, the non-standardised colour coding used by manufacturers of these filters, the number of different types of filters with different names, the variable optimal position of the filters, and whether a wet or a dry breathing system is being used, results in an extremely confusing situation. One of the leading manufacturers of these filters (Intersurgical) produces HME's that are blue, which is the same colour as the non-HME filters supplied to NHS by another company. A photograph of the non-HME blue filter is inconsistent with the photograph of the green HME and yellow non HME's shown on page 6 of the guidance for use of anaesthetic machines for the ventilation of adult critical care patients. In my experience, few doctors and nurses working in ICU are knowledgeable about all these different filters and which ones should be used for any given breathing system.
In my opinion, the confusion over breathing system filters and HMEs is widespread among ICU staff (doctors and nurses) and the classification and colour coding of these filters/HMEs is worthy of review, simplification, and standardisation.

The concerns raised by the independent expert are not confined to the Nightingale, emergency provision hospitals, but relate equally to all intensive care settings, particularly when the intensive care provision has to be extended to other areas of the hospital.

As there are still pressures within the ITU settings and in light of the imminent, planned reduction in COVID-19 safeguards, I consider that action should be taken to address this concern at the earliest possible stage.