Published: 14:00, 24 July 2014 |
Updated: 14:05, 24 July 2014
An 85-year-old man from Rolvenden died after a series of systematic failures that saw doctors at the William Harvey Hospital treat the wrong lung, a coroner has ruled.
Herbert Chandler, who suffered several chronic diseases and a collapsed left lung, passed away after the failings, an inquest concluded.
Known by family and friends as Jim, he died at the Ashford hospital on January 22 2013 - five days after he was admitted for a procedure that was supposed to help his breathing.
Instead, Dr Charlotte Tai wrongly aspirated his right lung - leading to terminal respiratory failure.
An aspiration is when the air between the chest wall and lung, which causes the collapse, is removed using a needle and syringe.
In her conclusion, coroner Rachel Redman found Dr Tai failed to request an X-ray before carrying out the procedure, despite the most recent scan being more than two days old.
The same doctor also failed to check the existing radiology immediately before the procedure and did not examine Mr Chandler to check her findings matched the data.
Earlier in the day, Dr Athanasios Nakos failed to fit Mr Chandler with a chest drain and did not pass on his findings to his colleagues.
The coroner also branded the hospital "conservative" for treating his condition with antibiotics, nebulisers and steroids and also found he had been inappropriately prescribed other medication.
The hospital also failed to provide an on-call respiratory consultant and kept medical records in a "confusing format".
Mr Chandler, of Thornden Lane, spent most of his life running Chandler's Nursery in Rolvenden Lane with his brothers.
He was the widower of Alma Chandler, with whom he was married to for almost 60 years, and is survived by two sons, three grandchildren and four great grandchildren.
A statement released by his sons Colin and Alan today said: "We have yet to see any proof that systems have been improved within the Trust since his death.
"We do now believe that the treatment provided to our father was unsatisfactory. He should not have been left to suffer for more than five days before any action was taken to ease his suffering.
"If earlier action had been taken then perhaps this 'out of hours' procedure would not have taken place at all or may not have resulted in a fatal consequence.
"We have made it clear to Doctor Tai, and have told her so personally, that we hold no ill feelings towards her and hope that she will continue with a successful medical career.
"We do now believe that the treatment provided to our father was unsatisfactory. He should not have been left to suffer for more than five days before any action was taken to ease his suffering..." - family statement
"We feel that she is another victim here, let down by some of her medical colleagues and the lack of systems put in place by management.
"Our father is missed by many friends, family, grandchildren and great grandchildren. We do not want his premature death to be in vain."
It is known in the NHS as a never event, meaning it was a very serious and largely preventable accident that should not happen if the correct procedures are followed.
Mrs Redman will now send a report to the chief executive of the East Kent Hospitals University NHS Foundation Trust.
Dr Tai still works for the trust, but Dr Nakos does not.
An East Kent Hospitals University NHS Foundation Trust spokesman said: "We would like to express our sincere sympathy to his family and apologise for the errors in his care.
"The trust has taken this incident extremely seriously and, following a detailed investigation, has put in place a series of steps to attempt to reduce the risk of these events from occurring again."
They added they are carefully considering the concerns of the coroner.
A new checklist for procedures on patients' lungs performed outside an operating theatre is already in place.
A new protocol for all procedures on patient's lungs has also been created.
In future, these procedures must be undertaken by two members of staff with a safety checklist also completed by two staff members.
Written consent must also be obtained before the procedure starts and clinical X-rays and other imaging must be reviewed in advance.
A recorded check against patient identification and clear marking of the site must also be carried out before the procedure.
Following treatment, a clear record of the post-procedure management plan must also be kept.
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