Marie Gretta Harding · Prevention of Future Deaths report

On 17/10/14 I opened an inquest into the death of Marie Gretta Harding who, at the date of her death was aged 63 years old. The inquest was resumed and concluded on 10/4/14
I found that the cause of death to be: -
1a. Chest drain insertion (inserted 12.10.14)
1b Pneumothorax
1c Emphysema

I concluded by way of a narrative as follows:
On 14/10/14 Marie Gretta Harding died from a known complication of a necessary elected therapeutic procedure.

On 6/10/14 Marie Gretta Harding, who had a history of chronic obstructive pulmonary disease was admitted to Bradford Royal Infirmary suffering from breathlessness, where she was found to have suffered a left sided pneumothorax necessitating a chest drain. Subsequently, on 12/10/14, a further chest drain was inserted which more likely than not penetrated her left lung and she deteriorated and died on 14/10/14.

During the course of the inquest I heard that their was no trust guidelines for the insertion of chest drains, lack of up to date training on chest drain insertion and an unawareness of the existence of the on call weekend availability of interventional radiologist. Although I acknowledge that the Trust has now fully instigated remedial changes in this regard;

• To review the national guidelines for the insertion of chest drains to ensure lessons learnt by all NHS Trusts in England and Wales