Recurring concern

Unsafe management of pneumothorax

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First reported 14 Oct 2013•Latest report 17 Jan 2023

Definition

What this concern includes

Includes failures of controls specifically dedicated to pneumothorax management, including recognition from imaging or clinical findings, diagnostic review, treatment selection, timely intervention, specialist review and avoidance of contraindicated procedures.

Not included

Excludes generic diagnostic, prescribing, communication or staffing deficiencies unless they directly concern pneumothorax management.
Excludes treatment or procedural failures involving other respiratory conditions unless the report explicitly identifies pneumothorax as the shared safety concern.
Excludes general delays in care where no pneumothorax-specific management failure is identified.
Excludes unrelated failures in medical records, radiology or clinical cover when they are not materially connected to the safe management of pneumothorax.

Reports: 4
Individual concerns: 6
Date range: 2013–2023
Stated actions: 6

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Barking, Havering and Redbridge University Hospitals NHS Trust1

Care Quality Commission1

Department of Health and Social Care1

East Kent Hospitals University NHS Foundation Trust1

Epsom and St Helier University Hospitals NHS Trust1

NHS England1

St Richard's Hospital1

University Hospitals Sussex NHS Foundation Trust1

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.

17 Jan2023
West Sussex
Concerns raised1
1. Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
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.
Actions described in response 6
1. Action
  Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
1. Action
  Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated planned
3. Action
  Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
  Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated planned
Respondent positions 3
1. Position
  The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
1. Position
  The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
  Stated by NHS EnglandOutside remit
AI-generated summary

Teegan Marie Barnard · 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

Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.

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
Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report
“1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation. Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces. Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest. ”
Source location
Teegan Marie Barnard · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.

Verbatim wording from the response
“However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.”

Source location
Response from St Richards Hospital
Page 2 · response
Published 23 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.

Verbatim wording from the response
“b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.”

Source location
Response from St Richards Hospital
Page 2 · response
Published 23 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.

Verbatim wording from the response
“b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.”

Source location
Response from St Richards Hospital
Page 2 · response
Published 23 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.

Verbatim wording from the response
“c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery-through the SALG’s Patient Safety Update.”

Source location
Response from St Richards Hospital
Page 2 · response
Published 23 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.

Verbatim wording from the response
“Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.”

Source location
Response from Royal College of Anaesthetists
Page 1 · response
Published 23 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.

Verbatim wording from the response
“Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.”

Source location
Response from Royal College of Anaesthetists
Page 1 · response
Published 23 January 2023
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 Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.

Verbatim wording from the response
“You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs.”

Source location
Response from St Richards Hospital
Page 2 · response
Published 23 January 2023
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 existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.

Verbatim wording from the response
“NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.”

Source location
Response from NHS England
Page 2 · response
Published 23 January 2023
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 identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.

Verbatim wording from the response
“I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.”

Source location
Response from Health Education England
Page 1 · response
Published 23 January 2023
Open published response
15 Jun2017
East London
Concerns raised1
1. Failure to avoid the swallow procedure in the presence of a left pneumothorax
This report raised 5 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.
AI-generated summary

Mr Kevin George Mann · 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

Mr Kevin George Mann underwent an Ivor Lewis procedure for oesophageal cancer and subsequently developed a pneumothorax. A Visipaque contrast study was performed despite the pneumothorax, and contrast entered his left main bronchus; his respiratory condition deteriorated and he later died. Concerns included failures to check available imaging and an outstanding chest x-ray request, to stop the procedure when contrast entered the bronchus, and to document the amount of contrast used.

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
Failure to avoid the swallow procedure in the presence of a left pneumothorax
Wider context from the report
“1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax. ”
Source location
Mr Kevin George Mann · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Aug2014
Central and South East Kent
Concerns raised2
1. Conservative management of left pneumothorax with antibiotics
2. Failure to insert a chest drain for pneumothorax
This report raised 7 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.
AI-generated summary

Herbert Chandler · 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

Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

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
Conservative management of left pneumothorax with antibiotics
Wider context from the report
“A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • 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, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”
Source location
Herbert Chandler · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to insert a chest drain for pneumothorax
Wider context from the report
“A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • 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, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”
Source location
Herbert Chandler · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Oct2013
Surrey
Concerns raised2
1. Delays in medical treatment following pneumothorax
2. Failure to recognise pneumothorax on X-rays
This report raised 7 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.
AI-generated summary

Frederick Davidson · 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

Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.

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 medical treatment following pneumothorax
Wider context from the report
“Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. • The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures • Unexplained and important gaps in the clinical notes • Breakdown in communication between the junior doctor and consultant. • The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. • The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. • Delay in the forwarding and receipt of x ray reports from radiology ”
Source location
Frederick Davidson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to recognise pneumothorax on X-rays
Wider context from the report
“Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. • The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures • Unexplained and important gaps in the clinical notes • Breakdown in communication between the junior doctor and consultant. • The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. • The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. • Delay in the forwarding and receipt of x ray reports from radiology ”
Source location
Frederick Davidson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to consider and exclude tension pneumothorax during PEA cardiac arrest

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to avoid the swallow procedure in the presence of a left pneumothorax

Concerns raised2

Conservative management of left pneumothorax with antibiotics

Failure to insert a chest drain for pneumothorax

Concerns raised2

Delays in medical treatment following pneumothorax

Failure to recognise pneumothorax on X-rays

Actions described in response 6

Respondent positions 3