STAFF errors while using ventilators may have caused Covid patients to die, according to a new report.
It comes amid claims medics used the wrong filters in a "cluster" of similar incidents involving the life-saving breathing system filters.
An inquest will now investigate the deaths of two patients at the London Nightingale Hospital in April last year after the East London Coroner issued a warning about the risk of future fatalities.
It is feared Kishorkumar Patel and Kofi Aning, 66, passed away at the temporary hospital while suffering from Covid after the wrong filters were used inside their intensive care ventilators.
The incidents have raised concerns regarding the awareness of ICU staff as they work through packed wards throughout the pandemic.
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.
Despite it not yet being determined whether the medical blunders were definitive factors in the pair's deaths, coroner Nadia Persaud took the unorthodox step to caution others in a prevention of future deaths report.
She said in both of the 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."
The report, sent to the Royal College of Anaesthetists and the Faculty of Intensive Care Medicine, revealed an independent expert said intensive care clinicians were dealing with "an extremely confusing situation."
"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," they said.
"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."
The independent expert warned the unorganised classification and colour coding of the crucial filters "is worthy of review, simplification, and standardisation."
"As there are still pressures within the ICU 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," the coroner added.
An inquest into the 66-year-old male's deaths is due to take place at Walthamstow Coroner's Court in October.
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