Terence Grainger · Prevention of Future Deaths report

On 18th April 2024, I opened an inquest into the death of Terence Grainger, who died on 10th February 2024 at The Alexandra Hospital, Cheadle, aged 61 years. The investigation concluded with an inquest which I heard on 22nd and 24th January, and 4th February 2025.

A post mortem examination determined Mr Grainger died as a consequence of:-

1) a) Acute left thoracic cavity haemorrhage
b) Removal of left-sided intercostal drain
c) Drainage of pleural effusion following coronary artery bypass graft surgery for ischaemic heart disease due to coronary artery atheroma.

The conclusion of the inquest was a Narrative Conclusion, to the effect that Mr Grainger died as a consequence of complications arising from chest drain insertion under ultrasound guidance, which first became apparent after the chest drain had been removed.

Mr Grainger died on 10th February 2024 at The Alexandra Hospital, Cheadle as a consequence of an acute left thoracic cavity haemorrhage due to removal of a left-sided intercostal drain which had been placed to drain a pleural effusion following coronary artery bypass graft surgery.

I am concerned that notwithstanding the limited steps Circle Healthgroup Ltd has taken towards introducing electronic patient records at its hospitals, the court heard evidence that no plans are currently in place to introduce an electronic system for recording patient observations.

I am concerned that an ongoing risk of future deaths arises from this position, in the view of the potential for such systems to accurately record timings of observations, facilitate trend analysis particularly in the context of a deteriorating patient, and reduce the potential for errors, either arising from incorrect / unclear manual recording of observations or miscalculating the NEWS 2 score.