Kenneth John WILLIAMS · Prevention of Future Deaths report

The inquest into Kenneth John Williams’s death was opened on the 28th June 2013 was resumed on the 17th March 2015. Conclusion was returned on the 30ᵗʰ March 2015.

The cause of death was:
1a – right haemothorax
1b – rupture of pulmonary bulla (by insertion of chest drain)

Box 3 was recorded as:
Kenneth John Williams was admitted to Epsom General Hospital with shortness of breath on the 23ʳᵈ June 2013. A diagnosis of tension pneumothorax was made and a chest drain was inserted. This was removed on the 24ᵗʰ June 2013 and after a deterioration in his health and the reinsertion of a chest drain he died on the 25th June 2013 at 10.30am. A subsequent review did not find a tension pneumothorax but a known emphysematous bulla.

And the conclusion was;

Kenneth John Williams died of complications following the insertion of a chest drain.

On the 23ʳᵈ June 2013, Kenneth John Williams was seen at Epsom General A&E for shortness of breath. A diagnosis of tension pneumothorax was made and a chest drain was inserted. Previous radiology was available to show the presentation diagnosed as a pneumothorax was actually an historic bulla. The initial chest drain collapsed the bulla and ruptured a vessel leading to progressive bleeding. The respiratory team were not involved and subsequent management proceeded upon the assumption the initial diagnosis of tension pneumothorax was correct. The Chest drain was removed on the 24ᵗʰ June 2013 and subsequently replaced when Mr Williams health began to deteriorate. Mr Williams passed away on the 25ᵗʰ June 2015.

1. Action is required to ensure that previous radiology, patients medical history and medication is always considered before a chest drain insertion or any invasive procedure is undertaken.

2. Action is required to ensure respiratory consultants opinion is sought where possible before inserting a chest drain.

3. Action is required to ensure the respiratory team is made aware of all patients who have had a chest drain inserted.

4. Action is required to ensure patents previous medical history, historical imaging and medications are always reviewed anew by any subsequent medical team receiving the patient from A&E.

5. Action is required to ensure all medical staff are trained how to access historical imaging.