Source · Prevention of Future Deaths
Marie Harding
Ref: 2015-0214
Date: 12 Jun 2015
Coroner: Martin Fleming
Area: West Yorkshire (West)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted the absence of trust guidelines for chest drain insertion, a lack of up-to-date staff training on the procedure, and an unawareness of interventional radiologist availability during weekends.
Date
12 Jun 2015
56-day deadline
7 Aug 2015 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted the absence of trust guidelines for chest drain insertion, a lack of up-to-date staff training on the procedure, and an unawareness of interventional radiologist availability during weekends.
View full coroner's concerns
During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains, lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist. Although I acknowledge that the Trust has now fully instigated remedial changes in this regard; The MATTER OF CONCERN is as follows. –
To review the national guidelines for the insertion of chest drains to ensure lessons learnt by all NHS Trusts in England and Wales
To review the national guidelines for the insertion of chest drains to ensure lessons learnt by all NHS Trusts in England and Wales
Report sections
Investigation and inquest
On 17/10/14 I opened an inquest into the death of Marie Gretta Harding who, at the date of her death was aged 63 years old. The inquest was resumed and concluded on 10/4/14 I found that the cause of death to be: ‐ 1a. Chest drain insertion (inserted 12.10.14) 1b Pneumothorax 1c Emphysema
I concluded by way of a narrative as follows: On 14/10/14 Marie Gretta Harding died from a known complication of a necessary elected therapeutic procedure.
I concluded by way of a narrative as follows: On 14/10/14 Marie Gretta Harding died from a known complication of a necessary elected therapeutic procedure.
Circumstances of the death
On 6/10/14 Marie Gretta Harding, who had a history of chronic obstructive pulmonary disease was admitted to Bradford Royal Infirmary suffering from breathlessness, where she was found to have suffered a left sided pneumothorax necessitating a chest drain. Subsequently, on 12/10/14, a further chest drain was inserted which more likely than not penetrated her left lung and she deteriorated and died on 14/10/14.
RT3589
RT3589
Copies sent to
I have sent a copy of this report toBradford Teaching Hospitals NHS TrustChief Coroner DATED this 12 June 2015RT3589 2
Similar PFD reports
Report details
- Reference
- 2015-0214
- Date of report
- 12 June 2015
- Coroner
- Martin Fleming
- Coroner area
- West Yorkshire (West)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Aug 2015 (estimated from the report date).
Sent to
- NHS England