Mr TAM - Non-inquest findings

62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation

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.