Background: Chest drain malposition is a well recognized safety issue. In 2008, the UK National Patient Safety Agency issued a safety alert regarding chest drain insertion after receiving reports of 12 deaths 2005-2008. British Thoracic Society pleural guidelines recommend that all procedures are carried out by a skilled operator under ultrasound guidance. If in the course of investigating a death a UK coroner is concerned that the circumstances giving rise to the death might arise again and could be prevented, then they have a legal duty to write a preventing future death (PFD) report. PFD reports are publicly available but have not been systematically examined in relation to chest drains.

Aims and Objectives: To systematically review all PFD reports that mention chest drains to identify common learning.

Methods: We wrote software to download and extract PFD report text data for c4000 deaths (each report relates to one death) covering the period July 2013-December 2022. We cleaned and indexed the data to make it searchable[1] and searched for "chest drain".

Results: 15 PFD reports mentioned chest drains. In six of these, chest drain malposition was the clear cause of death, in the remaining cases it was contributory or incidental. Of these six, two were likely due to inserting a chest drain into an existing haemothorax, one to inserting a drain into the heart, one to inserting the drain on the wrong side causing iatrogenic pneumothorax, and two to the chest drain being inserted into the lung. These reports represent the tip of the iceberg, highlighting the urgent need for hospitals to ensure adequate training and local guidelines for pleural procedures to prevent avoidable chest drain related deaths.

1. http://deathlessons.org/