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Air Tube Error Caused Baby's Death

Ventilation tube


A baby who was born four months prematurely died because a ventilation tube was mistakenly fed into her stomach rather than her lungs, a coroner has ruled.

Mariyam Salam survived for just eight days after being born and died on February 29, 2004, after the tube intended to help her breathe spent nine hours unnoticed in her oesophagus, and not her trachea.

Swindon Coroner's Court heard that, despite two sets of chest X-rays, doctors at Great Western Hospital (GWH) in Swindon failed to spot the error.

Wiltshire coroner David Masters, recording a narrative verdict, said: "The cause of death was acute respiratory failure due to the misplacement of the endotracheal tube. It is probable that had the misplaced endotracheal tube been recognised and replaced, Mariyam would have survived her acute deterioration on February 28 with the probability of her surviving overall increasing to around 70%."

Medics initially believed Mariyam had died from pneumonia linked to her prematurity and no post-mortem examination was carried out. But in May of 2004, Dr Lucy Grain, paediatric consultant at GWH's neo-natal unit, spotted the error when she re-examined X-rays at a meeting with Mariyam's parents.

She informed Swindon and Marlborough NHS Trust's legal team, explaining that she did not believe there had been a cover-up but rather a human error had been made in good faith.

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Mandy Luckman, Associate Solicitor in the Medical Law & Patients' Rights Department at Irwin Mitchell said: "The circumstances of Mariyam's death are particularly tragic as it appears to have been so easily avoidable. A high level of specialist training is required before a practitioner should carry out such a procedure and if there is any element of uncertainty as to whether the tube is located correctly, then this should be confirmed by an x-ray. It is difficult to understand how the mistake was missed and it naturally calls into question the level of expertise of those involved."