James Kane
15 Jul 2016 · Coroner Andrew Tweddle · County Durham and Darlington
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. drain insertion without ultrasound scan
“Notwithstanding that a local discussion of the circumstances of this case has taken place and there having been no local support for a change in policy or guidance, given the evidence that the deceased would not have died when he did but for the drain and that it is possible that a scan may have reduced the risk of death”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“Mr. [name redacted] was not examined prior to the insertion of the chest drain.”
This report
“given the evidence that the deceased would not have died when he did but for the drain”