Inquest into death of JAMIE LAWRENCE MITCHELL

36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to closed radiofrequency ablation of left atrial tract for treatment of atrial fibrillation

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.