Mr Marco Scarci Consultant Thoracic Surgeon · Expert Witness Discuss a case

Pleura

Pneumothorax and chest drain complications

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Chest drain insertion is a common procedure performed by relatively junior clinicians, frequently out of hours, and it generates a steady volume of negligence claims. The issues are usually narrow, the records are usually short, and the cases are often capable of early resolution once the surgical view is known.

Claims arising from chest drain insertion

Six recurring issues

Drains have been placed into the lung, the liver, the spleen, the heart, the great vessels, the diaphragm and the subclavian vessels. Whether the injury represents a recognised complication or a departure from acceptable practice usually turns on the site chosen, the technique used, whether imaging guidance was indicated, and the operator’s grade and supervision.

Whether the drain was placed within the safe triangle, and whether the departure from it — if there was one — was justified by the clinical circumstances.

Rare, always indefensible, and usually a systems failure rather than an individual one.

Practice has moved substantially. Whether ultrasound guidance should have been used depends on the indication and on the date, and I set out the standard at the material time.

A drain placed subcutaneously, in a fissure, or below the diaphragm may not drain, and the failure is often not appreciated for hours. Whether the post-insertion imaging was reviewed, and by whom, is generally the decisive point.

Claims arising from the management of pneumothorax

Where management goes wrong

Failure to diagnose pneumothorax on presentation, or to review the imaging that showed it Failure to recognise tension pneumothorax, where the diagnosis is clinical and delay is measured in minutes Inappropriate conservative management of a pneumothorax that required intervention, or intervention where observation was appropriate Failure to escalate a persistent air leak to a thoracic surgical opinion, and the timing at which that referral should have been made Failure to offer definitive surgical management after recurrent pneumothorax Iatrogenic pneumothorax following central line insertion, lung biopsy, pacemaker insertion or positive pressure ventilation, and the management that followed it

The questions I answer

Scope of opinion

01

Whether the decision to insert, or not to insert, a drain was reasonable

02

Whether the technique used met the required standard at the relevant date

03

Whether the complication was a recognised risk or a departure from acceptable practice

04

Whether the complication was recognised and managed within a reasonable time

05

Whether earlier thoracic surgical referral would have altered the course

06

The consequences of the injury and the prognosis

07

Whether the deterioration was survivable with correct management, in fatal cases

Why these cases are often resolved early

A short chronology, a small record

The chronology in a chest drain case is usually measured in hours and the documentary record is correspondingly small.

Where the imaging shows the drain in the wrong place and the notes show nobody looked at the imaging, the position is clear on both sides quickly.

Where it is genuinely a recognised complication properly managed, that is also clear quickly.

My preliminary view on these cases is often available on the merits call.

What I will need

Records
  • Emergency department and inpatient records
  • All imaging as images, including the film taken before insertion and every film taken after it
  • The procedure record
  • Observation charts
  • The consent form where one exists

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