X-ray blunderled to death ofretired miner

The botched procedure left 85-year-old Eric Oliver dying in bed just a few minutes later.

Coroner Nicola Mundy highlighted a series of errors which led to the widower’s death as she gave a narrative verdict.

The cause of death was given as a collapsed lung due to the medical procedure and afterwards Mr Oliver’s son Michael, 58, said: “It should never have happened in the first place.”

Mr Oliver needed fluid draining from his right lung but junior doctor Jonathan Hurst attempted to syringe the left, withdrawing only air.

The doctor told the hearing in Rotherham, South Yorkshire: “What I hadn’t done is flip the X-ray round hence why I went to the left side.”

Mr Oliver, a father of 11 with more than 100 grandchildren and great-grandchildren, had been in a jovial mood at Rotherham District Hospital.

He suffered from chronic obstructive pulmonary disease and was transferred to hospital on May 23 last year.

The procedure involved inserting a needle in the patient’s back and withdrawing fluid with a syringe. On-call doctor Rohit Bazaz had left Dr Hurst to drain the fluid hoping that Mr Oliver could be discharged to a local respiratory centre later that day.

The junior doctor had observed the procedure a handful of times and carried it out once under supervision. After discussing the X-ray with Dr Bazaz he said he felt confident in doing it alone.

Student nurse Liam Godsil said Dr Hurst twice tried to withdraw fluid. He added: “The patient’s breathing was very laboured within a minute of the needle being withdrawn. He was struggling and looked a bit panicked.”

Dr Hurst admitted he had not “flipped” the X-ray round.

Mr Oliver, of Herringthorpe, Rotherham who had recovered from four previous heart attacks, deteriorated rapidly and he died minutes later.

Delivering her verdict the coroner said it was “entirely reasonable” for the junior doctor to undertake the plural tap himself.

But there were no facilities for viewing the X-ray in the treatment room and he was relying on his memory.

Ms Mundy said: “I am satisfied there was an immediate and rapid deterioration in his condition and Dr Hurst should have suspected this.”

She said urgent medical intervention was required yet it took eight minutes for a crash team to be called after Mr Oliver suffered a heart attack.

The coroner said the junior doctor was responsible for poor management. He could have acted by inserting a needle to relieve the pressure on the lung or asking a more senior doctor to do a chest drain and on the balance of probabilities Mr Oliver would have survived.

“Instead there was a failure to take effective steps to manage the situation and valuable time was spent,” she said.

Although Dr Hurst twice consulted Dr Vazaz, the senior doctor was not made aware of how ill the patient was or provided with the relevant information.

“Had he been told he would have asked for a crash team to be called,” said the coroner. She said the junior had made a “fundamental error”and decided to further assess the patient rather than treat him immediately which made the situation worse.

“It is quite clear the aspiration set off the chain of events which led to death,” she said.

Ms Mundy said the decline of the patient was a “profound and direct” link to the procedure and “early intervention would on the balance of probabilities led to the situation being rescued and Mr Oliver surviving.”

In her verdict she said despite the series or errors it did not amount to gross failure to provide basic medical attention.

She was satisfied Rotherham Hospital had since taken steps to improve communications to prevent it happening again.