Recurance · prevention of future deaths reports
Pre-inquest brief
Chest drain insertion without pre-procedure checks
The earlier warning
Gerald Werrett · 1 Aug 2014 · M E Voisin, Avon
“Mr. [name redacted] was not examined prior to the insertion of the chest drain.”
judiciary.uk/prevention-of-future-death-reports/gerald-werrett
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 15 Jul 2016 · James Kane · Andrew Tweddle · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Gerald Werrett · 1 Aug 2014
“Mr. [name redacted] was not examined prior to the insertion of the chest drain.”
Later · James Kane · 15 Jul 2016
“given the evidence that the deceased would not have died when he did but for the drain”
What happened next
No web check of the stated actions has been published for this chain.