Upali Meththananda: Prevention of Future Deaths Report

Hospital Death (Clinical Procedures and medical management) related deaths

Skip to related content

Date of report: 17/06/2025 

Ref: 2025-0308 

Deceased name: Upali Meththananda   

Coroners name: Catherine Wood 

Coroners Area: North East Kent 

Category: Hospital Death (Clinical Procedures and medical management) related deaths 

This report is being sent to: East Kent Hospitals NHS Trust 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
THIS REPORT IS BEING SENT TO:

Chief Executive, East Kent Hospitals NHS Trust 
1CORONER 

I am Ms. Catherine Wood Assistant Coroner for North East Kent   
2CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and  regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3INVESTIGATION and INQUEST 

On 6 November 2023 I commenced an investigation into the death of Upali METHTHANANDA. The investigation concluded at the end of the inquest . The  conclusion of the inquest was Narrative   

“He died as a result of bleeding from a severed blood vessel, a rare but recognised  complication of thoracentesis. The haemorrhage occurred following the insertion of a chest  drain to drain fluid from a left sided pleural effusion which arose as a complication of coronary artery bypass surgery for his underlying ischaemic heart disease.” 

1a   Multi-Organ Failure 
1b   Hypovolemic Shock 
1c  Bleeding following thoracentesis (20 October 2023) for a pleural effusion following cardiothoracic surgery (3 October 2023) 
1d     
 II     Chronic Lymphocytic Lymphoma, Cerebrovascular Accident (Stroke) in the Past 
4CIRCUMSTANCES OF THE DEATH 

Upali Meththananada was a 76 year old physiotherapist who despite his age was still working  and active. He had a medical history of hypertension, ischaemic heart disease, chronic  lymphocytic leukaemia and previous stroke when he began to suffer from chest pain in early  2023. Coronary angiography revealed severe triple vessel disease and he was referred for  coronary artery bypass surgery at St. Bartholomew’s hospital. He underwent surgery at St.  Bartholomew’s on 3 October 2023 and his aorta was found to be heavily calcified so a decision  was made to conduct the procedure without cardiopulmonary bypass. The procedure itself was complicated by bleeding and he required a number of blood products during surgery. He  recovered following surgery but had a residual pleural effusion following removal of his chest  drains but he was fit for discharge home when he left hospital on 10 October 2023. 

He presented by ambulance to the Queen Elizabeth the Queen Mother hospital with chest pain and shortness of breath on 17 October 2023 and was admitted to the Coronary Care unit. Imaging revealed a large left sided pleural effusion which was creating a midline shift and  following discussions with his earlier treating cardiologist, treating cardiothoracic surgeon and  the cardiologist at Queen Elizabeth the Queen Mother hospital a decision was made to perform a chest drain locally. 

The chest drain was inserted on the afternoon of 20 October 2023 at around 14.30 -15.00 and  700mls of blood stained fluid drained before the drain was removed. He was initially stable but  following the insertion he collapsed with signs of hypovoleamia at 15.45 . An emergency call was initiated and help summonsed and attempts were made to correct his hypovolemia using  blood products and drugs and discussions held with the team at St. Bartholomew’s about  transferring him. He remained unstable and at around 18.15 suffered from a cardiorespiratory  arrest and despite continued attempts at resuscitation including a thoracotomy to stem any  bleeding he died at 19.40. 
5CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In my  opinion there is a risk that future deaths will occur unless action is taken. In the circumstances  it is my statutory duty to report to you. 
  
The MATTERS OF CONCERN are as follows. – 

(1) I was concerned about the documentation as the inquest process had been hampered by  the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of  documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations  taken even in the period prior to his collapse. Clinical observations were not documented,   meaning that trends were not available to treating clinicians and they would not have a full  picture upon which to base any clinical decisions. Discussions between clinicians at other  organisations were also not documented and forms used by the hospital for procedures were  not used as required even by experienced clinicians. Whilst I heard some improvements had  been made by the witness who presented the Trust’s action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties  could lead to clinicians who take over care for a patient not having a full picture and leading to  risks to patients in the future.   
6ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you the Chief  Executive at East Kent Hospitals NHS Trust have the power to take such action. 
7YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 August 2025. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out the  timetable for action. Otherwise you must explain why no action is proposed. 
8COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 

Mr. Meththanada’s family and Barts NHS Trust.   

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or summary form. He  may send a copy of this report to any person who he believes may find it useful or of interest.  You may make representations to me, the coroner, at the time of your response, about the  release or the publication of your response by the Chief Coroner. 
917 June 2025 
Signature                                   
Catherine Wood Area Coroner for North East Kent