“The evidence revealed that there were no local cardiothoracic department protocols that…”
Dated 31 Jan 2017, from the coroner for South Wales Central. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 28 Mar 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated31 Jan 2017
- Deadline28 Mar 2017
- Published on judiciary.uk19 Feb 2017
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) The evidence revealed that there were no local cardiothoracic department protocols that were available to guide the insertion of intercostal drains and no specific training given to new medical and nursing staff. (2) The British Thoracic Society Guidelines strongly support the use of real time ultrasound guidance when inserling chest drains for fluid. Real time ultrasound guidance was not available in this case.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0013
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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