- Herbert Chander died in January at the William Harvey Hospital in Kent
- He was admitted after suffering chronic diseases and a collapsed left lung
- Inquest heard doctors took him to theatre for a procedure but in a fatal error the surgeon operated on the right lung
- Great-grandfather-of-four died three hours after the operation
- Coroner said ‘series of failings’ by hospital caused the 85-year-old’s death
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Herbert Chandler died in January after doctors at the William Harvey Hospital in Ashford inserted a chest drain into the wrong lung, causing it to collapse
A ‘series of failings’ at a Kent hospital led to the death of a great-grandfather after doctors operated on the wrong lung.
Herbert Chandler, 85, was rushed to hospital with several chronic diseases and a collapsed left lung.
Doctors took him into theatre for a procedure to help his breathing – but in a fatal error, the surgeon operated on his right one.
The great-grandfather-of-four, who had been admitted five days earlier to William Harvey Hospital in Ashford, Kent, died just three hours after the operation.
Coroner Rachel Redman, concluding the inquest in Folkestone, Kent, said a number of ‘failings’ by the hospital led to Mr Chandler’s death.
Ms Redman said: ‘Mr Chandler suffered from chronic obstructive pulmonary disease and a left pneumothorax [air that is trapped next to a lung].
‘A series of failings by the Trust have caused or contributed to the cause of death.’
She added that an ‘erroneous aspiration’ – the drainage of air or fluid – in the right chest cavity caused his death after a number of ‘systematic errors’.
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.
But the inquest heard she had been given an inaccurate medical note written by another doctor which said the right lung needed treatment – when it was the left.
When she discovered she had treated the wrong lung she carried out an aspiration on the right one.
But both lungs had by then collapsed and Mr Chandler, from Rolvenden, Kent, died about three hours after the treatment.
The inquest heard there were a number of blunders made before the procedure, including failing to give Mr Chandler a chest drain.
In her conclusion, Ms 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 inquest heard the William Harvey Hospital in Ashford, Kent apologised to Mr Chander’s family and has implemented a raft of changes to ensure similar mistakes are not made in the future
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.
The
coroner branded the hospital ‘conservative’ for treating his
condition with antibiotics, nebulisers and steroids and found he
had been inappropriately prescribed other medication.
Furthermore, it failed to provide an on-call respiratory consultant and
kept medical records in a ‘confusing format’, the coroner said.
In
a statement, Mr Chandler’s heartbroken sons Colin and Alan said their father, who ran a nursery all his life with his brothers,
should not have ‘been left to suffer’.
Mr Chandler’s sons Alan and Colin said: â€Our father is missed by many friends, family, grandchildren and great grandchildren’
They 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
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.’
Mr
Chandler was the widower of Alma Chandler, with whom he was married to
for almost 60 years.
He is survived by two sons, three grandchildren
and four great grandchildren.
Dr Tai still works for East Kent Hospitals University NHS Foundation Trust. But Dr Athanasios Nakos, who was supposed to fit the chest drain, does not.
A 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.’
He
added they are carefully considering the concerns of the coroner and
new protocol and checklists for all procedures on patient’s lungs has
also been put in place.
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