PFD report

Herbert Chandler · Prevention of Future Deaths report

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Issued 21 Aug 2014•Central and South East Kent

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.

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Concerns
9

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised9

  1. Conservative management of left pneumothorax with antibiotics
    Part of recurring concern: Unsafe management of pneumothorax
  2. Failure to examine the patient immediately before right-lung aspiration
  3. Confusing medical-record format preventing sequential recording of entries
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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 clearly linked to these concerns.

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

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. ”

Is this part of a recurring concern?

Yes — Unsafe management of pneumothorax.

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 examine the patient immediately before right-lung aspiration

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Confusing medical-record format preventing sequential recording of entries

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. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 request a chest X-ray before aspiration

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. ”

Is this part of a recurring concern?

Yes — Unreliable X-ray request and progression processes; Unreliable chest X-ray referral and ordering.

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management; Unsafe management of pneumothorax.

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 provide consultant on-call respiratory cover

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. ”

Is this part of a recurring concern?

Yes — Insufficient safe staffing and senior cover out of hours.

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

Inappropriate prescribing of gentamicin and aminophylline

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. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 check radiology immediately before right-lung aspiration

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 communicate consultant review findings to the medical on-call team

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. ”

Is this part of a recurring concern?

Yes — Unreliable recording and confirmation of specialist clinical advice.

Open source report
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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