Finding into death of Neville Ross

65y · Male·Cardiac tamponade whilst undergoing CT-guided pericardiocentesis; perforation of right ventricle during drainage procedure

A 65-year-old man with history of left pneumonectomy, COPD and cardiomyopathy died from cardiac tamponade during CT-guided pericardiocentesis. Key clinical issues: (1) Necessity of procedure was questionable—patient presented for routine echo before scheduled cardiology appointment, appeared clinically well to family and examining registrar despite cardiologist's later assertions of clinical deterioration; (2) diagnosis of tamponade relied on subjective clinical findings (pulsus paradoxus) documented only retrospectively after death, with disagreement among experts about echo findings; (3) Dr C., patient's longstanding cardiologist, was not consulted despite explicit patient/family request and his documented history monitoring the effusion since 2001; (4) procedure technique: left parasternal approach chosen over sub-xiphoid despite targeting smaller fluid pocket that progressively diminished during procedure, increasing perforation risk. Expert opinion suggested procedure may not have been necessary or appropriate for this high-risk patient. Systemic issues included absence of contemporaneous clinical documentation and confusion about urgency level.