Finding into death of Trevor Ronald McDonald

Contributing factors

• Perforation of right coronary artery during angioplasty
• Laceration of right ventricular outflow tract during pericardiocentesis needle insertion
• Pericardiocentesis performed without ultrasound guidance
• Prolonged cardiac tamponade with inadequate initial relief
• Delayed access to cardiothoracic surgical facilities
• Significant delay in inter-hospital transfer (2 hours 45 minutes)
• Delay in locating receiving hospital with available theatre and ICU bed
• Extended period of cerebral hypoxia from approximately 3:35pm to 5:00pm
• Patient moved and restless during pericardiocentesis, complicating needle placement

Coroner's recommendations

1. Peninsula Health should ensure the Director of Frankston Hospital PCI Unit is an experienced interventional cardiologist who is cross-accredited to at least one tertiary cardiothoracic unit and practices interventional cardiology at Frankston
2. Department of Health request the Intensive Care Advisory Committee to consider access to intensive care beds for emergency cardiac surgical patients in the context of overall intensive care bed supply in the State
3. Department of Health seek advice from the Cardiac Clinical Network to integrate its role in emergency transfer of patients from stand-alone regional PCI units with services of the Intensive Care Advisory Committee and Adult Retrieval Victoria
4. Cardiac Society of Australia and New Zealand consult with Department of Health and Cardiac Clinical Network to ensure guidelines for stand-alone regional PCI units account for local arrangements that reduce time for emergency transfer to tertiary cardiothoracic units
5. Cardiac Society of Australia and New Zealand reconsider advice about transfer time from stand-alone regional PCI units to include time required to locate a bed in a receiving hospital and time for emergency transfer
6. Cardiac Society of Australia and New Zealand review guidelines to require all interventional cardiologists performing angioplasties in regional stand-alone PCI Suites to be cross-credentialled to tertiary high-volume cardiothoracic units and work in such units for sufficient time to maintain exposure to emergency responses