Recurring concern

Failure to provide timely access to clinically required chest drainage

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First reported 16 Dec 2019•Latest report 27 Jul 2020

Definition

What this concern includes

Includes failures in the dedicated chest-drainage access pathway, including timely local provision, availability of appropriately capable staff or services, escalation and transfer to tertiary centres when local capacity is unavailable, where these delay or prevent clinically required drainage.

Not included

  • Excludes generic staffing, workload or capacity deficiencies that are not specifically tied to delayed access to clinically required chest drainage.
  • Excludes delays in unrelated investigations, procedures or treatments, including other forms of thoracic or surgical care.
  • Excludes failures in chest-drain management after the procedure has been completed unless they directly concern access to the required drainage procedure.
  • Excludes transfer delays unrelated to obtaining clinically required chest drainage.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2019–2020

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Greater Manchester Health and Social Care Partnership2
NHS England1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Samuel Garner · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in performing clinically required chest drainage due to competing staff demands

    Wider context from the report

    “3. He waited a number of hours for his chest to be drained (after it was identified that was what was required) due to competing demands on clinical staff. He was in significant distress whilst waiting. ”

    Source location

    Samuel Garner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

    Verbatim wording from the response

    “It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

    Source location

    2020-0145-Response-from-DHSC_Redacted.pdf
    Page 2 · response
    Published 1 October 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The chest drain was inserted within 100 minutes of the decision; delays reflected clinical requirements, not competing staff demands.

    Verbatim wording from the response

    “Therefore, the decision to insert the chest drain was made at 2030hrs when the ST1 documents the advice from cardiothoracics. The drain had been inserted no more than 100 minutes later. Mr Garner was moved from cubicle 13 to resus bed 2 at 2054hrs which would imply no actual delay, as he needed to be in the right place and such a procedure requires equipment and personnel to be assembled, and then the procedure takes some time. The attending doctor records it to have been an uncomplicated procedure. Oramorph was given at 1823hrs and IV paracetamol after the drain was inserted, and often significant amounts of analgesia are necessary to facilitate the drain insertion, but that was not required. There are multiple nursing entries that do not suggest him to be in pain or discomfort. His oxygen requirement improved dramatically after the drain.”

    Source location

    2020-0145-Response-from-GMHSCP_Redacted.pdf
    Page 4 · response
    Published 1 October 2020

    Open published response

  2. Manchester South

    AI-generated summary

    Joyce Marchant · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays and impracticability in transferring patients to tertiary centres for drainage procedures

    Wider context from the report

    “1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May. There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable. The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away; ”

    Source location

    Joyce Marchant · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026