Prevention of Future Deaths report – Kishorkumar Patel and Kofi Aning

Summary

Kishorkumar Patel and Kofi 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.

Content

The Coroner highlights concerns raised by an independent expert in regards to the non-standardised colour coding used by the manufacturers of the filters on breathing systems of intensive care ventilators, noting that there is widespread confusion among Intensive Care Unit staff about their classification and colour coding.

The report states this issue is not confined to Nightingale hospitals, but relates equally to all intensive care settings. It was sent to the Royal College of Anaesthetists and Faculty of Intensive Care Medicine for action and response.