Published: 12:00, 04 June 2014
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.
“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:
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.
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.
East Kent Hospitals University NHS Foundation Trust, which runs the William Harvey, said it would be unable to comment before the verdict.
Every morning at 10am we play you an hour of tunes from the 90s. We call it, #WeLoveThe90s.
Play 'Say It' with Garry and Laura on kmfm Breakfast and you could win £1,000!
Wake up to kmfm Breakfast with Garry and Laura - it's Kent's alarm call.