Coroner's Finding: ALLEN Richard Grant

60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardiac pacemaker

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 H.), 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.