Coroner's Finding: HN de-identified

83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal pericardial haemorrhage from pericardiocentesis

An 83-year-old woman presented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented. A pericardiocentesis was performed by a registrar (rather than an experienced cardiologist) under emergency physician supervision. The procedure caused traumatic pericardial haemorrhage leading to cardiac tamponade and death. Critical deficiencies in medical documentation—missing ECGs, echocardiogram reports, and procedure notes—severely hampered investigation. Standard practice dictates pericardiocentesis should be performed by experienced cardiologists with echocardiographic guidance. The substandard documentation compromised both patient care and post-mortem investigation.