Permanent pacemaker implantation is a low-risk procedure. However, complications may occur with a rate of around 3-8%. We present a case where initial implantation resulted in complications that could have been avoided by meticulous assessment of lead position in different projections and early post procedure X-ray that would have delineated other serious complications. An eighty-seven-year-old female patient presented with syncope and documented high grade atrioventricular block. She had a dual chamber pacemaker implant, after which she had another episode of syncope with loss of pacing capture. This was rectified by ventricular lead repositioning that resulted in consistent ventricular pacing. A week later, she was re-admitted with worsening dyspnoea and fatigue. Chest X-ray (CXR) and CT revealed haemopericardium and haemothorax and she was treated with a chest drain and conservatively managed for pericardial effusion. She had a slow recovery and was discharged home after treatment with no further symptoms during follow up in pacing clinic. This case emphasises the importance of meticulous assessment during and after pacemaker implantation.