Finding into death of Giuseppe Costa

75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment of right pleural effusion

Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainage with no clear record of cessation of drainage; removal of the catheter at 7.30pm despite persistent effusion shown on CT scan at 5.50pm; failure to activate MET calls despite vital sign deterioration meeting criteria at 4.00-4.30am; unclear documentation of 'Not for MET Calls' with no indication who wrote it or when; incomplete vital sign recording not compliant with national standards; poor communication of radiological findings to treating clinicians. The catheter likely damaged the intercostal artery, which may have been tamponaded while in situ. Upon removal, uncontrolled bleeding occurred, leading to haemothorax and death. Systemic issues included substandard observation charting, inadequate drainage documentation, and missed opportunities for escalation and clinical intervention.