Non-inquest findings into the death of RJH

70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide cardioversion due to urinary tract infection, against a background of coronary artery atherosclerosis, emphysema, and obesity

A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021. A locum senior medical officer prescribed intravenous flecainide 300mg total (two 150mg doses) for cardioversion without cardiology consultation, despite recent chest X-ray showing congestive cardiac failure—a documented contraindication to flecainide for decades. Cognitive bias from successful prior flecainide use led to failure to recognise new contraindications. The patient was haemodynamically stable; waiting 24-48 hours for infection control would have been safer. Absent pharmacy cover meant no independent safety review of the unusual dosing and lack of protocol. ECG changes between infusions were not acted upon. Clinical lessons: recognise cognitive bias from prior successes, maintain cardiology consultation for complex cases, utilise available pharmacy consultation services, and review ECG parameters before administering repeat doses.