ROBERT CHARLES CHANDLER · Prevention of Future Deaths report

On 27 September 2018, I commenced an investigation into the death of ROBERT CHARLES CHANDLER, AGED 85. The investigation concluded at the end of the inquest on 20 FEBRUARY 2019. The conclusion of the inquest was medical cause of death: 1a) Respiratory Failure b) Traumatic Pneumothorax 2. Chronic Obstructive Pulmonary Disease, Dementia, Ischaemic Heart Disease, Frailty and a Narrative Conclusion: On 24 September 2018, Mr Chandler collapsed and suffered a pneumothorax. An ambulance arrived fifty minutes after the first telephone call was received and Mr Chandler was taken to the James Paget University Hospital where he died on 25 September 2018 from his injury.

On 24 September 2018, Mr Chandler collapsed and suffered a pneumothorax. An ambulance arrived fifty minutes after the first telephone call was received and Mr Chandler was taken to the James Paget University Hospital where he died on 25 September 2018 from his injury.

(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used.
(2) Staff are required to ask for assistance when required and are responsible for checking equipment daily. The evidence is that this is not always done.
(3) An electronic tablet was used initially to record the incident but this was not sufficiently charged to record all information. Paper records were not adequately completed.
(4) The incident occurred in September 2018 and the internal investigation report with recommendations was completed in January 2019. Recommendations within the Report and in particular a clinical debrief had not taken place at the time of inquest (February 2019)