A series of failings by the Trust have caused or contributed to the cause of death, namely:-  A conservative approach to managing the left pneumothorax with antibiotics,  Inappropriate prescribing of medication, namely gentamicin and aminophylline,  A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,  A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,  The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,  The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,  A confusing format of medical records which prevented sequential recording of entries by health care professionals,  A failure to provide Consultant on call respiratory cover.