John Crittall

“The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of”

“The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity.”

“The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining. I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr [name redacted] death.”

“Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a background of poor communication with the ward staff as to what plan was in place”

“The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments.”

“There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist”