An elderly woman died after a doctor accidentally punctured her lung while performing a chest drain procedure, a coroner has ruled.

Judith Seymour Sheehan, 76, was admitted to Wellington Hospital with fluid on her lung in April 2010, Coroner Ian Smith said in his finding.

He was told doctors decided to drain the area with a small 3cm needle in an attempt to avoid lung damage.

The registrar who performed the procedure, Dr Ilamaran Kumarasamy, known as Dr Moran, was an advanced trainee in general medicine.


Following the draining Mrs Sheehan became increasingly breathless and Dr Moran contacted a consultant Elaine Barrington-Ward, Coroner Smith said.

"At the time Mrs Sheehan was notably distressed and clammy, short of breath and only talking in short sentences."

She underwent medical intervention, but died in the Intensive Care Unit at the hospital later that day.

A post mortem examination found there had been an "inadvertent" puncturing of the lung that resulted in a haemorrhage, cardiac arrest and death.

A Capital Coast District Health Board review team made a number of recommendations, including always using an ultrasound before the procedure.

Coroner Smith noted in his conclusion that he hoped a dedicated ultrasound machine was now available.

CCDHB deputy chief medical officer Grant Pidgeon "unreservedly apologised" to Mrs Sheehan's family.

"Capital and Coast DHB fully accepts its responsibility for providing safe health care. Any incident which involves a patient suffering harm or death while in our care is one event too many."

An internal review found that the decision to treat Mrs Sheehan by attempting to drain the fluid was reasonable and took into account her history, Dr Pidgeon said.

"Following this incident the training of registrars undertaking this procedure has been enhanced, and the importance of pre-procedure ultrasound marking has been stressed.

"These teachings are now part of a regular in-service programme."

The respiratory team also had a dedicated ultrasound machine that was routinely used, he said.