endeavouring to place the sheath over the lead at the time the lead came free. In any event, there is no evidence that the lead came free because of any deliberate or careless action on the part of any person. Dr Hii told me, and I accept his evidence, that in the 200 or so procedures that he had conducted he had only ever had one perforation and that was something that required no serious intervention and resolved itself quickly. Dr Hii had never had any event of this nature occur in the past. In short there is simply no evidence to suggest that Dr Hii applied an undue amount of force on the lead. I accept Dr Hii’s evidence that it came away in the course of the application of the sheath. As to why it came away, and in particular how an amount of force sufficient to cause the perforation was applied to the lead before Dr Hii was ready with the sheath is unfortunately a matter that will never be fully understood. Mr Allen’s procedure and the circumstances of his death were examined by an independent expert, Dr Glenn Young, who provided three reports. In none of these reports did Dr Young suggest that Dr Hii’s decision to persist with the extraction was wrong or that his methods of extraction were either inappropriate or ineptly executed. In fact in his first report Dr Young said: 'It is evident from my viewing of the case documentation that the procedure was performed for entirely appropriate indications.' The only observation that Dr Young appears to make about the ventricular lead extraction was that it did not appear from the clinical record that a telescopic sheath had been used. However, as earlier indicated, I accept Dr Hii’s evidence that it was in the process of his endeavouring to secure the sheath that the ventricular lead, as it were, accidentally came away. As will be seen, however, Dr Young commented unfavourably upon the absence of backup measures, particularly diagnostic measures, during the performance of the procedure. In particular, Dr Young was critical of the fact that a diagnosis of a ventricular perforation was not made in a timely manner and that attempts to rectify the resulting cardiac tamponade were consequently delayed. I will return to that issue in due course. Events following Mr Allen’s deterioration
endeavouring to place the sheath over the lead at the time the lead came free. In any event, there is no evidence that the lead came free because of any deliberate or careless action on the part of any person. Dr Hii told me, and I accept his evidence, that in the 200 or so procedures that he had conducted he had only ever had one perforation and that was something that required no serious intervention and resolved itself quickly. Dr Hii had never had any event of this nature occur in the past. In short there is simply no evidence to suggest that Dr Hii applied an undue amount of force on the lead. I accept Dr Hii’s evidence that it came away in the course of the application of the sheath. As to why it came away, and in particular how an amount of force sufficient to cause the perforation was applied to the lead before Dr Hii was ready with the sheath is unfortunately a matter that will never be fully understood. Mr Allen’s procedure and the circumstances of his death were examined by an independent expert, Dr Glenn Young, who provided three reports. In none of these reports did Dr Young suggest that Dr Hii’s decision to persist with the extraction was wrong or that his methods of extraction were either inappropriate or ineptly executed. In fact in his first report Dr Young said: 'It is evident from my viewing of the case documentation that the procedure was performed for entirely appropriate indications.' The only observation that Dr Young appears to make about the ventricular lead extraction was that it did not appear from the clinical record that a telescopic sheath had been used. However, as earlier indicated, I accept Dr Hii’s evidence that it was in the process of his endeavouring to secure the sheath that the ventricular lead, as it were, accidentally came away. As will be seen, however, Dr Young commented unfavourably upon the absence of backup measures, particularly diagnostic measures, during the performance of the procedure. In particular, Dr Young was critical of the fact that a diagnosis of a ventricular perforation was not made in a timely manner and that attempts to rectify the resulting cardiac tamponade were consequently delayed. I will return to that issue in due course. Events following Mr Allen’s deterioration