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Chain of errors leads to Herbert 'Jim' Chandler dying after being treated for the wrong lung at William Harvey Hospital in Ashford

By Sam Lennon

A chain of errors led to a man being treated for the wrong lung - ending in both collapsing.

Herbert ‘Jim’ Chandler died after the hospital blunder in which the right hand lung was worked on when it should have been the left, an inquest heard.

Respiratory consultant Dr Simon Bourne, who reviewed the case as an independent expert, said: “There was a chain of errors that led to the death. There was a failure to intervene early.

Herbert Chandler died in the William Harvey hospital

“You could say there was not a system in place for a respiratory patient.”

Mr Chandler, 85, of Thornden Lane, Rolvenden, died at the William Harvey Hospital in Ashford on January 22, 2013, five days after being brought in as an emergency case with pneumothorax (collapsed lung).

The blunders were:

  • He was never given a chest drain when, Dr Bourne said, that should have been done on the first day.
  • A consultant involved did not communicate over the situation directly with the registrar who carried out the procedure.
  • That registrar had been passed an inaccurate medical note written by another doctor, which said the right lung needed treatment when it was the left.
  • A series of doctors had overlooked that mistake.
  • That note had been taken in isolation when it was part of a series of notes made during Mr Chandler’s stay, by the same doctor. All the other notes identified the correct lung.

The registrar, Dr Charlotte Tai carried out a procedure on Mr Chandler, called an aspiration, on the evening of January 22.

This is when air between the chest wall and lung, which causes the collapse, is removed using a needle and syringe

When she discovered she had treated the wrong lung she carried out an aspiration on the right one.

But both lungs had by now collapsed and he died about three hours after the treatment.

Folkestone magistrates' court, where the inquest was heard

This hearing was a resumption after a previous one last January 22, which turned out to be the first anniversary of the death.

It was then that Dr Adrian Morris, who listed the wrong lung on the medical note, and Dr Athanasios Nakos, the consultant who didn’t communicate directly with Dr Tai, gave evidence.

Rachel Redman, Central and South East Kent coroner, adjourned the hearing at Folkestone Magistrates Court.

She will give her summing up and verdict at the next hearing for this case, the date of which will be confirmed.

The hospital has apologised to Lena

East Kent Hospitals University NHS Foundation Trust, which runs the William Harvey, said it would be unable to comment before the verdict.

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