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Pleural disease management is underpinned by diagnostic and therapeutic procedural intervention, most commonly pleural aspiration and chest drain insertion. These interventions are inherently invasive and carry recognised risk, including organ puncture and death. Landmark recommendations from the National Patient Safety Agency 1 drove a nationwide step change in respiratory practice by mandating the use of thoracic ultrasound (TUS) before pleural intervention for fluid, a requirement now clearly embedded within recently updated British Thoracic Society (BTS) guidance.2 Despite this, significant harm from pleural procedures continues to be reported, and the reasons for this remain incompletely understood.3 4