PFD report

Gerald Trevor WERRETT · Prevention of Future Deaths report

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Issued 1 Aug 2014•Avon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
12

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure to examine patients prior to chest drain insertion
    Part of recurring concern: Failure to perform clinically indicated physical examinationsPart of recurring concern: Unreliable chest drain insertion and management
  2. Incorrect interpretation of the cardiac silhouette
    Part of recurring concern: Unreliable chest X-ray imaging and interpretationPart of recurring concern: Unreliable interpretation of diagnostic imaging
  3. Misinterpretation of chest x-rays
    Part of recurring concern: Unreliable chest X-ray imaging and interpretationPart of recurring concern: Unreliable interpretation of diagnostic imaging
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 recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 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.
  2. 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 recipient says about a concern when it does not describe a specific action.2

  1. Position

    Local services should review the environment, clinician training, ultrasound availability and rapid reporting arrangements.

    Stated by Royal College of Emergency MedicineRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to examine patients prior to chest drain insertion

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Failure to perform clinically indicated physical examinations; Unreliable chest drain insertion and management.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Incorrect interpretation of the cardiac silhouette

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation; Unreliable interpretation of diagnostic imaging.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Misinterpretation of chest x-rays

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation; Unreliable interpretation of diagnostic imaging.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to use a lead anatomical marker when taking chest x-rays

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure by clinicians to identify incorrectly labelled chest x-rays

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consider both chest x-rays

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Incorrect labelling of chest x-rays

Wider context from the report

“Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included: 1. A lead anatomical marker was not used when taking the chest x-ray 2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician 3. The chest x-ray that was looked at was misinterpreted 4. Both chest x-rays were not considered. 5. The cardiac silhouette was not interpreted correctly 6. Mr. Werrett was not examined prior to the insertion of the chest drain. ”

Is this part of a recurring concern?

Yes — Unreliable chest X-ray imaging and interpretation.

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

Publish and make freely accessible updated pleural disease guidance covering safe chest-drain insertion.

Verbatim wording from the response

“In 2010 the British Thoracic Society published an 82 page update on management of pleural disease which includes safe insertion of chest drains (Thorax 2010 (August) Vol. 65, supplement 2). This publication is freely available in most medical libraries and, more importantly, is available on the British Thoracic Society website which is open to all individuals. It is one of the most frequently visited sections of the Society’s website.”

Source location

2014-0355-Response-by-British-Thoracic-Society
Page 1 · response
Published 1 August 2014

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

Work with colleagues to identify, learn from and share lessons from the chest-drain incident.

Verbatim wording from the response

“General aspects - The College was alerted to a specific chest drain insertion problem earlier this year which led to notification to our safety network in March 2014. The initial notification and subsequent alert were completely anonymised; however, from the detail you have provided we now believe this was the same incident you now highlight and our ongoing work with colleagues will focus on lessons to be learned and shared from this situation.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Local services should review the environment, clinician training, ultrasound availability and rapid reporting arrangements.

Verbatim wording from the response

“Following this incident, the key things we feel that should be reviewed locally are whether the environment supports the review of X-rays (e.g. availability of IT in the room where the procedure was carried out), if the doctor was trained in the use of ultrasound guidance for insertion of chest drains and whether ultrasound was available, in addition to the availability of rapid 24 hour reporting.”

Source location

2014-0355-Response-by-The-College-of-Emergency-Medicine
Page 1 · response
Published 1 August 2014

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

Responsibility for reviewing and potentially reissuing the chest-drain safety alert lies with NHS England’s safety department.

Verbatim wording from the response

“You would wish to be aware of an alert issued by the National Patient Safety Agency (NPSA) in May 2008 regarding chest drains (http://www.nrls.npsa.nhs.uk/resources/?EntryId=45987) and this is still a key point of reference for anaesthetists and others in their safe use. Despite the closure of the NPSA we believe the responsibility for these alerts continues through the safety department within NHS England and we have advised them of this death, with anonymised detail, and requested they review the alert and consider its re-issue.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Publish North Bristol NHS Trust’s safety checklist and guidelines on the College website once received.

    Stated by Royal College of Emergency MedicineStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.
  2. 2

    Highlight the case and investigation findings in the next Safety Newsflash to members.

    Stated by Royal College of Emergency MedicineStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.
  3. 3

    Issue an alert to senior anaesthetists, risk managers and clinical directors urging checks of local chest-drain policies and procedures.

    Stated by Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 1 August 2014.
  4. 4

    Advise NHS England about the death and request review of the chest-drain alert, including consideration of re-issue.

    Stated by Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 1 August 2014.
  5. 5

    Highlight safe practice and double-checking the correct insertion site to Intensive Care Society event organisers.

    Stated by Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 1 August 2014.
  6. 6

    Ensure the next annual training review gives particular attention to correct chest-drain insertion site selection.

    Stated by Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.
  7. 7

    Ask the Safe Anaesthesia Liaison Group to forward chest-drain incident reports promptly for closer monitoring and remedial action where necessary.

    Stated by Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.
  8. 8

    Progress safety messaging on chest-drain insertion through the safety network to other providers of anaesthesia CPD events.

    Stated by Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.
  9. 9

    Remind College training and education directors to stress correct chest-drain insertion techniques throughout professional development and continuing practice.

    Stated by Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 1 August 2014.
  10. 10

    Highlight safe chest-drain insertion practice at future College events covering chest drains.

    Stated by Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 1 August 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing British Thoracic Society chest-drain guidance is freely available, comprehensive and more recent than the National Patient Safety Agency information.

    Stated by The British Thoracic SocietyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Publish North Bristol NHS Trust’s safety checklist and guidelines on the College website once received.

Verbatim wording from the response

“The College shares your concerns, and will take the following actions:”

Source location

2014-0355-Response-by-The-College-of-Emergency-Medicine
Page 1 · response
Published 1 August 2014

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

Highlight the case and investigation findings in the next Safety Newsflash to members.

Verbatim wording from the response

“The College shares your concerns, and will take the following actions:”

Source location

2014-0355-Response-by-The-College-of-Emergency-Medicine
Page 1 · response
Published 1 August 2014

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

Issue an alert to senior anaesthetists, risk managers and clinical directors urging checks of local chest-drain policies and procedures.

Verbatim wording from the response

“I have reminded each of the directors in the College, with responsibility for training and education, about the need to continue to stress the importance of correct chest drain insertion techniques at all stages of professional development and beyond this into continuing practice. As stated in my previous letter, I have also issued an alert to our network of senior anaesthetists, risk managers and clinical directors (approximately 800 healthcare staff across the UK) about the need to check local policy and procedures to ensure ongoing vigilance where chest drains are to be used. Finally, through our Safe Anaesthesia Liaison Group we will now ask for reports related to chest drain insertion incidents to be forwarded to us as soon as they occur so we may monitor any incidence of problems more closely and take remedial action where necessary.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Advise NHS England about the death and request review of the chest-drain alert, including consideration of re-issue.

Verbatim wording from the response

“You would wish to be aware of an alert issued by the National Patient Safety Agency (NPSA) in May 2008 regarding chest drains (http://www.nrls.npsa.nhs.uk/resources/?EntryId=45987) and this is still a key point of reference for anaesthetists and others in their safe use. Despite the closure of the NPSA we believe the responsibility for these alerts continues through the safety department within NHS England and we have advised them of this death, with anonymised detail, and requested they review the alert and consider its re-issue.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Highlight safe practice and double-checking the correct insertion site to Intensive Care Society event organisers.

Verbatim wording from the response

“our calendar for the immediate future; however, when this occurs we will highlight the need to emphasise further safe practice at insertion. In addition, we have also identified this is a frequent topic for events managed by colleagues at the Intensive Care Society and have highlighted to them a need to stress safe practice and double checking the correct site before insertion. Actions to highlight the issue to other providers of events earning anaesthesia CPD credit will be progressed through our safety network as below.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Ensure the next annual training review gives particular attention to correct chest-drain insertion site selection.

Verbatim wording from the response

“Training and trainees – chest drain insertion is covered at several stages of the anaesthesia training curriculum. Initial insertion techniques are assessed at the basic level of training and management responsibilities for the procedure progress through training, and across increasingly complex environments. Subsequent training and work-place based assessment advances to the longer term management of patients with chest drains and dealing with emergency patients and trauma situations. These areas of training are under annual review by our Training Committee and we will ensure particular attention is attached to correct site location at the next review.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 1 · response
Published 1 August 2014

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

Ask the Safe Anaesthesia Liaison Group to forward chest-drain incident reports promptly for closer monitoring and remedial action where necessary.

Verbatim wording from the response

“I have reminded each of the directors in the College, with responsibility for training and education, about the need to continue to stress the importance of correct chest drain insertion techniques at all stages of professional development and beyond this into continuing practice. As stated in my previous letter, I have also issued an alert to our network of senior anaesthetists, risk managers and clinical directors (approximately 800 healthcare staff across the UK) about the need to check local policy and procedures to ensure ongoing vigilance where chest drains are to be used. Finally, through our Safe Anaesthesia Liaison Group we will now ask for reports related to chest drain insertion incidents to be forwarded to us as soon as they occur so we may monitor any incidence of problems more closely and take remedial action where necessary.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Progress safety messaging on chest-drain insertion through the safety network to other providers of anaesthesia CPD events.

Verbatim wording from the response

“our calendar for the immediate future; however, when this occurs we will highlight the need to emphasise further safe practice at insertion. In addition, we have also identified this is a frequent topic for events managed by colleagues at the Intensive Care Society and have highlighted to them a need to stress safe practice and double checking the correct site before insertion. Actions to highlight the issue to other providers of events earning anaesthesia CPD credit will be progressed through our safety network as below.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Remind College training and education directors to stress correct chest-drain insertion techniques throughout professional development and continuing practice.

Verbatim wording from the response

“I have reminded each of the directors in the College, with responsibility for training and education, about the need to continue to stress the importance of correct chest drain insertion techniques at all stages of professional development and beyond this into continuing practice. As stated in my previous letter, I have also issued an alert to our network of senior anaesthetists, risk managers and clinical directors (approximately 800 healthcare staff across the UK) about the need to check local policy and procedures to ensure ongoing vigilance where chest drains are to be used. Finally, through our Safe Anaesthesia Liaison Group we will now ask for reports related to chest drain insertion incidents to be forwarded to us as soon as they occur so we may monitor any incidence of problems more closely and take remedial action where necessary.”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 2 · response
Published 1 August 2014

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

Highlight safe chest-drain insertion practice at future College events covering chest drains.

Verbatim wording from the response

“Several past professional CPD events have been identified where the use of chest drains, particularly with the inclusion of chest ultrasound, has been covered. We can find no similar planned events in”

Source location

2014-0355-Response-by-The-Royal-College-of-Anaesthetists
Page 1 · response
Published 1 August 2014

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

Existing British Thoracic Society chest-drain guidance is freely available, comprehensive and more recent than the National Patient Safety Agency information.

Verbatim wording from the response

“Regrettably, harm from chest drains is well recognised. The National Patient Safety Agency (NPSA) produced a Rapid Response Report and supporting information in May 2008. The latter gives background information and refers very clearly to the Guideline which was developed by the British Thoracic Society in 2003. The Rapid Response report states clearly questions that the team should ask about before placement of chest drains.”

Source location

2014-0355-Response-by-British-Thoracic-Society
Page 1 · response
Published 1 August 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026