Coronial
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Coroner's Finding: ALLEN Richard Grant

Deceased

Richard Grant Allen

Demographics

60y, male

Date of death

2005-11-02

Finding date

2008-09-19

Cause of death

haemopericardium due to rupture of right ventricle complicating removal of cardiac pacemaker

AI-generated summary

Richard Allen, a 60-year-old man with a permanent pacemaker for sick sinus syndrome, died from haemopericardium due to rupture of the right ventricle during pacemaker lead extraction on 2 November 2005. The 14mm perforation created catastrophic bleeding into the pericardial space causing cardiac tamponade. Although the procedure was appropriately indicated for an infected pacemaker and performed by an experienced electrophysiologist (Dr Hii), critical failures occurred post-perforation: the echocardiography machine needed for rapid diagnosis was not immediately available (situated 100 metres away), leading to a 20-25 minute diagnostic delay while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the haemopericardium diagnosis would have been made promptly, allowing earlier pericardiocentesis and possibly improved survival chances. While a 14mm tear would likely have proven fatal regardless, the delay and absence of cardiothoracic surgical backup on-site represented departures from CSANZ guidelines that created preventable morbidity risks.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyanaesthesiacardiothoracic surgery

Error types

diagnosticdelaysystem

Drugs involved

propofolsedative agents

Clinical conditions

sick sinus syndromecardiac arrhythmiapacemaker infectionright ventricular perforationhaemopericardiumcardiac tamponadeelectromechanical dissociationcardiac arrest

Procedures

pacemaker removallead extractionstylet applicationsheath-assisted lead removalpericardiocentesispulmonary angiogramarterial line insertion (attempted)

Contributing factors

  • 14mm rupture of anterior aspect of right ventricle near apex
  • lead extraction procedure in patient with 11-year-old lead with significant adhesions and fibrosis
  • delay in diagnosis of cardiac tamponade (20-25 minutes)
  • echocardiography machine not immediately available
  • time spent performing unproductive pulmonary angiogram instead of pericardiocentesis
  • absent cardiothoracic surgical backup on-site at time of collapse
  • procedure conducted late in afternoon when practice had closed and equipment not accessible
  • diagnostic ultrasound capability not in procedure room or immediately retrievable

Coroner's recommendations

  1. The Cardiac Society of Australia and New Zealand (CSANZ) Executive Officer and Lead Extraction Advisory Committee Convener should clarify minimal facility requirements for lead extraction to further emphasise need for cardiothoracic surgeon on-site and capable of initiating emergency procedure promptly
  2. CSANZ should recommend that lead extraction procedures take place in an operating theatre
  3. CSANZ should define 'immediately available' in terms conveying necessity for diagnostic ultrasound capability to be available within time of significant diagnostic utility, preferably within the procedure room
  4. The Minister for Health and Chief Executive Officer of the Medical Board of South Australia should encourage CSANZ to take the steps described above
  5. The Minister for Health and Chief Executive Officer of the Medical Board of South Australia should ensure that cardiac pacemaker lead extraction procedures are conducted in accordance with CSANZ guidelines
  6. Chief Executive Officers of all hospitals or clinics in South Australia performing cardiac pacemaker lead extraction procedures should ensure procedures are performed in accordance with CSANZ guidelines
Full text
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Source and disclaimer

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