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Coroner issues ‘Prevention of Future Death report’ following Inquest

11 June 2015

An 81 year old man (KW) was admitted to Epsom General Hospital in June 2013 suffering from shortness of breath. He sadly died two days later following the insertion of an unnecessary chest drain, having suffered a haemothorax upon its removal.

KW had a history of significant chronic obstructive pulmonary disease (COPD) and emphysematous bullous disease. He had a large bulla (air pocket within the lung space often caused by COPD) in his right lung, which was identified for the first time three years previously, in 2010. There was a failure to review the previous chest radiography, which was available. As a result, KW’s chest x-ray was misinterpreted as being a tension pneumothorax for which a chest drain was inserted. A subsequent review did not find a tension pneumothorax but a known emphysematous bulla. The respiratory team were not involved and subsequent management proceeded on the basis that the diagnosis was correct. HM Coroner found that there was a missed opportunity to assess the situation afresh when KW was reviewed the following day. KW’s care could have been escalated at this point, though in all likelihood the subsequent management was not the cause of his death. The initial chest drain collapsed the pulmonary bulla and ruptured the vessel leading to progressive bleeding. Surgery may well have prevented the bleeding had matters been recognised at an earlier stage. In the event, this did not occur.

HM Area Coroner for Surrey, Simon Wickens, ordered that a prevention of future death report be made, given that the evidence heard at the Inquest had revealed a number of matters that gave rise to concern.

The family were given support in relation to the inquest by AvMA, the UK charity for patient safety and justice assistance. They arranged for a barrister, Dominic Ruck Keene of 1 Crown Office Row to represent the family on a pro bono basis.