Deceased
TAM
Demographics
62y, male
Coroner
McDougall
Date of death
2013-11-14
Finding date
2017-09-20
Cause of death
Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation
AI-generated summary
Mr TAM, a 62-year-old man with multiple cardiac conditions, died from multi-organ infarction secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation. The fistula is a rare but recognised complication of ablation, with no clear preventive strategy. Clinical opinion found the management collaborative and reasonable, meeting appropriate standards of care. However, the cardiologist's record-keeping was found inadequate—clinical notes were not contemporaneous and were amended retrospectively, including on the date of death. Key clinical lessons include maintaining high suspicion for this devastating complication, ensuring prompt diagnostic evaluation of post-ablation chest pain, and maintaining accurate contemporaneous records. While informed consent discussions occurred, written information sheets are now standard practice.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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