{
  "abstract": "Background Cardiac tamponade is a life-threatening and challenging condition involving fluid accumulation in the pericardium. Coroners in the United Kingdom must write publicly available preventing future deaths (PFD) reports if they identify contributing factors that could prevent recurrence of mortality. We sought to analyze these reports for cardiac tamponade.Methods We formulated new software to download and extract PFD reports’ text data using Pdfminer and Pytesseract for 4650 reports from 01/08/2013 to 07/10/2024. We processed and indexed the data to make it searchable with Tantivy, and searched for ‘cardiac tamponade’ and ‘tamponade’.Results We identified 13 PFD reports accounting for 15 total deaths mentioning cardiac tamponade. Of these 15 deaths, cardiac tamponade was the cause of death in 11, and incidental in the remaining 4. Where directly attributable, 6 (55%) of cardiac tamponade deaths were at the management level, secondary to iatrogenic injury judged to be avoidable. Four of these were among neonates during central line insertion for umbilical venous catheterization. The other two were during insertion of a pacemaker and pacing wires for percutaneous coronary intervention. Four cases were at the diagnosis level: two premature discharges resulted in out-of-hospital sudden death secondary to tamponade from a missed aortic root aneurysm and dissection, another was due to missed heart failure from sepsis leading to tamponade, while the fourth was a missed ventricular fibrillation secondary to aortic dissection and resulting tamponade. The final preventable death was at the public health level, where the improper layout of a road junction led to a motor vehicle collision causing a traumatic tamponade.Conclusion Iatrogenic injury and missed diagnoses were common themes of preventable deaths related to cardiac tamponade. Targeted quality improvement interventions involving education on clinical recognition, procedural up-skilling, and appropriate safety-netting may reduce mortality secondary to tamponade.",
  "authors": [
    {
      "affiliations": [
        "Imperial College London"
      ],
      "name": "Ian YH Chan"
    },
    {
      "affiliations": [
        "Barts Health NHS Trust"
      ],
      "name": "Saad I Mallah"
    },
    {
      "affiliations": [
        "National Heart and Lung Institute"
      ],
      "name": "Keir EJ Philip"
    },
    {
      "affiliations": [
        "National Heart and Lung Institute"
      ],
      "name": "Carl Reynolds"
    }
  ],
  "title": "1-010 Preventable deaths from cardiac tamponade: a national 10-year report on coroner inquiries",
  "uid": "f63d3a1d-dbc8-51a3-889d-63908c683d42"
}