Coroner raps doctor over 'wrong lung' blunder

Eric Oliver (85) died after junior doctor Jonathan Hurst forgot to flip the x-ray which showed fluid on the former miner’s right lung and punctured his left lung instead.

Mr Oliver—a granddad and great granddad to more than 100—suffered a collapsed lung and was not given the “simple” reinflation procedure.

The Rotherham Coroner, Ms Nicola Mundy, gave her findings at Wednesday’s inquest, criticising Dr Hurst for:

Ordering another x-ray instead of calling the crash team for emergency treatment.
Leaving a declining Mr Oliver in the hands of radiographers and a student nurse.
Failing to give them a clear instruction to take the patient back to the ward.
Wasting valuable minutes by not making the patient’s serious condition clear to his supervisor.

She said: “There was a significant time lapse between abandoning the procedure and Mr Oliver going into arrest. It seems to me that early intervention would have led to the situation being resolved.”

Dr Hurst said in evidence that he had the right side in mind before entering the treatment room—which had no facility to display the x-ray.

Evidence about how quickly Mr Oliver declined was inconsistent.

Dr Hurst was certain that Mr Oliver, of Herringthorpe, had a pulse and was breathing but unclear about how conscious he was.

Ms Mundy said radiographer Mandy Archibald’s account of him being vacant and unresponsive was “credible and clear.”

While there were grave consequences, Ms Mundy said, the May 2009 incident did not amount to gross negligence.

Mr Oliver’s daughter, Vicky Oliver-Ripley bsaid after the hearing that the family was pleased that Rotherham General Hospital had reviewed its procedures after Mr Oliver’s death.

A family statement added: “We find it difficult to understand how a doctor could make such a basic error and then fail to take simple steps which could have saved his life.

“We are pleased that the hospital has accepted the seriousness of this tragic event we hope that this will make him a better doctor.”

Mr Oliver’s son Alan (56) said: “Don’t get me wrong, some of the nurses were brilliant. But he had gone in with chest problems and they still didn’t have oxygen masks to hand.

“We can understand that everyone’s human and makes mistakes but doctors seem to have bad memories when it comes to the awkward questions.”

Ms Mundy recorded a narrative verdict, saying: “Eric Oliver developed serious complications following a right-sided pleural effusion being performed on the wrong side.

“Failure to expeditiously treat a left-sided pneumothorax had the immediate and profound effect of leading to cardio-respiratory arrest, from which Mr Oliver could not be resuscitated.”

A hospital spokeswoman said that processes and procedures had been reviewed.

She added: “Improvements included the introduction of a medical procedures checklist adapted from the World Health Organisation and training in the use of reporting tools to ensure good teamwork and communication.

“We introduced human factor training, which helps people recognise behaviours and conditions which can lead to human error so they are better equipped to avoid such errors.

“We aim to deliver the best levels of patient care and are committed to learning from any situation where changes can be made to improve what we do.”

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