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recurance

Herbert Chandler

21 Aug 2014 · Coroner Rachel Redman · Kent (Central & South East)

The coroner's concerns

  1. 1. conservative management of left pneumothorax

    “A conservative approach to managing the left pneumothorax with antibiotics”
  2. 2. inappropriate medication prescribing

    “Inappropriate prescribing of medication, namely gentamicin and aminophylline”
  3. 3. failure to insert chest drain

    “A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant [name redacted]”
  4. 4. failure to communicate findings

    “A failure to communicate findings after a Consultant's review on 22nd January to the medical on-call team”
  5. 5. failure to request chest x ray before aspiration

    “The Medical Registrar's failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray”
  6. 6. failure to verify radiology before aspiration

    “The Medical Registrar's failure to check the radiology immediately prior to aspirating the right lung”

Responses

No published response was found on judiciary.uk.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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