Inquest into death of JEFFREY BROWN

72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboembolitic disease; fibrinous pericarditis and CABG surgery as significant contributing conditions

Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known post-CABG complication) with acute bleeding into the pericardium causing cardiac tamponade. Although the family raised concerns about delayed diagnoses and missed opportunities to escalate care, independent expert review concluded anticoagulation was medically necessary and appropriate, and that the acute nature of the bleed made earlier diagnosis unlikely. Serial ECGs lacked characteristic tamponade findings. The coroner found no preventable failures in medical management, no matter of public safety, and no adverse findings against treating clinicians.