First reported 1 Aug 2014•Latest report 27 Jul 2020
Definition
What this concern includes
Includes failures in the dedicated chest-drain process, including independent assessment of indications, consent, procedural guidance, competency and training, imaging guidance, staffing and specialist availability, procedural checklists, observations, ward communication, post-procedure monitoring and escalation of complications.
Not included
Excludes generic radiology, respiratory, staffing, training or communication deficiencies unless they directly impair the chest-drain insertion or management process.
Excludes unrelated drains, catheters and invasive procedures unless the assertion explicitly concerns chest drains or intercostal drains.
Excludes failures in treating a complication after appropriate chest-drain management and escalation have already occurred.
Excludes general diagnostic-imaging access or interpretation failures where chest-drain insertion or management is not the material unsafe condition.
Reports
7
Distinct published reports
Individual concerns
21
A report can raise multiple concerns
Date range
2014–2020
First to latest report issue date
Stated actions
20
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
Cardiff & Vale University LHB1
Care Quality Commission1
Circle Health Group Limited1
East Kent Hospitals University NHS Foundation Trust1
Epsom and St Helier University Hospitals NHS Trust1
General Medical Council1
Greater Manchester Health and Social Care Partnership1
NHS England1
Royal College of Anaesthetists1
Royal College of Emergency Medicine1
Royal College of Radiologists1
Royal Surrey County Hospital1
The British Thoracic Society1
Health professional body2
Ministerial department2
NHS trust2
Executive non-departmental public body1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Health-system partnership1
Local health board1
Private limited company1
Registered charity1
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.
Manchester South
Concerns raised1
Delays in performing clinically required chest drainage due to competing staff demands
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The chest drain was inserted within 100 minutes of the decision; delays reflected clinical requirements, not competing staff demands.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised3
Lack of specific training for new medical and nursing staff in intercostal drain insertion
Unavailability of real-time ultrasound guidance for fluid chest drain insertion
Lack of local cardiothoracic department protocols for intercostal drain insertion
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Review the need for specific chest drain induction with the Welsh Deanery.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Provide bespoke thoracic ultrasound training for the Cardiothoracic Directorate.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Implement and oversee ongoing ultrasound training and competence assessment across the Health Board.
Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Implement direct ultrasound guidance for chest drain insertion and discontinue marked-spot insertion.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Purchase two additional ultrasound machines suitable for chest drain and pleural procedures.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Explore implementing a safety checklist for chest drain insertion.
Stated by Cwm Taf Morgannwg University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Failure to complete consent detailing chest drain complications
Poor communication of the post-procedure care plan to ward staff
Proactive chest drain insertion without objective clinical evidence
Failure to use real-time ultrasound guidance for chest drain insertion
Failure to establish clinical necessity for chest drain insertion
Insufficient nursing competence in resuscitation and chest drain management
Lack of independent radiological indications for chest drain insertion
Chest drain insertion decisions influenced by the day of the week
Failure to radiologically confirm the position of a non-draining chest drain
Failure to record observations before and after chest drain procedures
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Action
Update the chest-drain care protocol to align with British Thoracic Society guidance.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Include chest-drain complication management procedures within the patient pathway for ward staff.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Develop a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Develop a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Make Fellows and members aware of the BTS Pleural Disease Guideline 2010 Quick Reference Guide.
Stated by Royal College of RadiologistsStated plannedThe respondent said that this action was planned when they made their response on 16 May 2016.
Action
Run regular unannounced resuscitation scenarios for staff and RMOs, identifying learning requirements for follow-up.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Train nursing staff and healthcare assistants in acute illness management and assess competencies for caring for deteriorating patients.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Review and incorporate chest-drain insertion training and competencies for radiology and nursing staff into Acute Care Competencies.
Stated by Circle Health Group LimitedStated in progressThe respondent said that this action was in progress when they made their response on 16 May 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.
Stated by Circle Health Group LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Continuous hospital and radiology staffing, including an on-call radiographer, meant chest-drain decisions need not be influenced by the day of the week.
Stated by Circle Health Group LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The proactive chest-drain approach was attributed only to the consultants concerned, with no evidence that other hospital consultants adopted it.
Stated by Circle Health Group LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Nursing staff had required resuscitation training, with senior nurses generally holding advanced life-support certification.
Stated by Circle Health Group LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Yorkshire (Western)
Concerns raised2
Lack of trust guidelines for chest drain insertion
Lack of up-to-date training on chest drain insertion
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised2
Failure to notify the respiratory team about patients with inserted chest drains
Failure to seek respiratory consultant opinion before chest drain insertion
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Cascade instructions requiring respiratory-team involvement and notification for every patient who has had a chest drain inserted.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 March 2015.
Action
Use a spontaneous-pneumothorax pathway requiring respiratory-team discussion before chest-drain insertion.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 March 2015.
Central and South East Kent
Concerns raised1
Failure to insert a chest drain for pneumothorax
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Avon
Concerns raised1
Failure to examine patients prior to chest drain insertion
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Publish and make freely accessible updated pleural disease guidance covering safe chest-drain insertion.
Stated by The British Thoracic SocietyStated completedThe respondent said that this action was complete when they made their response on 1 August 2014.
Action
Work with colleagues to identify, learn from and share lessons from the chest-drain incident.
Stated by Royal College of AnaesthetistsStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for reviewing and potentially reissuing the chest-drain safety alert lies with NHS England’s safety department.
Stated by Royal College of AnaesthetistsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in the dedicated chest-drain process, including independent assessment of indications, consent, procedural guidance, competency and training, imaging guidance, staffing and specialist availability, procedural checklists, observations, ward communication, post-procedure monitoring and escalation of complications.
