Gerald Werrett

1 Aug 2014 · Coroner M E Voisin · Avon

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

1. mislabelled chest x-rays leading to wrong side chest drain insertion
“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences”
2. incorrectly labelled chest x-rays
“Both chest x-rays were incorrectly labelled, and this error was not identied by the clinician The”
3. misinterpretation of cardiac silhouette
“The cardiac silhouette was not interpreted correctly”
4. insertion of chest drain without prior clinical examination
“Mr. [name redacted] was not examined prior to the insertion of the chest drain”

Raised again laterJames Kane15 Jul 2016 · 1 year 11 months later

Closely relatedConfidence 0.80 · moderate

This report

“Mr. [name redacted] was not examined prior to the insertion of the chest drain.”

Later report

“given the evidence that the deceased would not have died when he did but for the drain”

Stated action · next review

“we will ensure particular attention is attached to correct site location at the next review.”