Coronial
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Inquest into death of JAMIE LAWRENCE MITCHELL

Deceased

Jamie Lawrence Mitchell

Demographics

36y, male

Coroner

Coroner Morrison

Date of death

2014-11-01

Finding date

2019-11-22

Cause of death

Septicaemia and cerebral artery air embolism, due to complications related to closed radiofrequency ablation of left atrial tract for treatment of atrial fibrillation

AI-generated summary

Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Adelaide Hospital, which was not detected pre-discharge. Presentation with post-procedural chest pain at Goulburn Base Hospital on 4 October was initially attributed to pericarditis, a known ablation complication. The fistula and infection developed over several days, diagnosed on 10 October after CT imaging. Urgent surgery at The Canberra Hospital and Calvary occurred with delay, followed by sepsis despite treatment. The coroner, applying strict causation principles, determined no public hearing was necessary and found no matters of public safety arising, despite family submissions questioning pre-procedure assessment, technique details, post-discharge information, and management at regional hospitals. Expert evidence differed on whether earlier CT scanning might have detected developing fistula.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologycardiothoracic surgeryemergency medicinegeneral practicegeneral surgeryintensive care

Error types

diagnosticdelay

Clinical conditions

atrial fibrillationatrioesophageal fistulaoesophageal perforationthermal injurypericarditissepticaemiafungaemiaE coli faecalis septicaemiacerebral artery air embolismmultiple embolic strokespseudoaneurysm

Procedures

radiofrequency ablation of left atrial conduction pathwayemergency surgical repair of atrio-oesophageal fistulaintercostal patch repair of oesophageal perforationlaparotomy with insertion of gastrostomy tube

Contributing factors

  • Atrioesophageal fistula development following radiofrequency ablation
  • Thermal injury to oesophagus during ablation procedure
  • Delay in diagnosis of fistula (4-10 October)
  • Infection and fungaemia following surgical repair
  • Septic complications with multiple embolic strokes
  • Inadequate post-discharge monitoring and follow-up information

Coroner's recommendations

  1. A copy of the findings be forwarded to the Cardiac Society of Australia & New Zealand for their information and any action they consider appropriate, noting the need for more research about patients with post-ablation oesophageal complications
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