PFD report

SANDRA HAZEL ELIZABETH HIGHAM · Prevention of Future Deaths report

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Issued 3 Nov 2014•London (Inner South)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Lack of awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk
  2. Difficulty diagnosing atrial-oesophageal fistula in acute medical settings
  3. Risk of atrial-oesophageal fistula following ablation procedures
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Work with patient organisations to redesign AF ablation complication information and develop downloadable symptom-awareness leaflets for patient discharge.

    Stated by British Heart Rhythm SocietyStated plannedThe respondent said that this action was planned when they made their response on 3 November 2014.
  2. Action

    Publish an article on avoiding and recognising atrio-oesophageal fistula in the winter newsletter circulated to members.

    Stated by British Heart Rhythm SocietyStated plannedThe respondent said that this action was planned when they made their response on 3 November 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    There is no evidence that newer ablation technologies or oesophageal temperature monitoring significantly reduce atrio-oesophageal fistula occurrence.

    Stated by British Heart Rhythm SocietyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of awareness among the wider medical profession of atrial-oesophageal fistula as an ablation risk

Wider context from the report

“(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival. (5) Diagnosing an atrial-oesophageal fistula can be difficult, especially in an acute medical setting, given its range of non-specific symptoms and duration of onset, and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Difficulty diagnosing atrial-oesophageal fistula in acute medical settings

Wider context from the report

“(4) According to the literature there are no clear predictors of mortality from an atrial-oesophageal fistula, but early diagnosis, prompt surgical intervention and prolonged antibiotic therapy may be crucial for survival. (5) Diagnosing an atrial-oesophageal fistula can be difficult, especially in an acute medical setting, given its range of non-specific symptoms and duration of onset, and the lack of awareness within the wider medical profession of such a fistula being a risk of the ablation procedure. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Risk of atrial-oesophageal fistula following ablation procedures

Wider context from the report

“(2) The development of an atrial-oesophageal fistula is a very rare, but known, risk of the ablation procedure (developing in around 0.01-0.2% of cases of percutaneous ablation and around 1-1.5% of cases of surgical ablation). (3) If an atrial-oesophageal fistula does develop, it has a very high mortality rate (reported to be 67-100%). ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with patient organisations to redesign AF ablation complication information and develop downloadable symptom-awareness leaflets for patient discharge.

Verbatim wording from the response

“The second area is patient education and this is likely to be of more benefit. Patients can be made more aware of this complication and also warning signs such as fever, epigastric pain, headache etc. They need to be told in this situation to (a) go to their local emergency department immediately and (b) they should contact the centre where the ablation was performed. We feel we should work with our sister organisations, the AF Association and the Arrhythmia Alliance (A-A) both of which are patient oriented organisations to improve the information and education patients are given; the information leaflets and online information produced by these organisations will be amended to reflect this. We will work to develop a leaflet which can be downloaded from these sites.”

Source location

2014-0479-Response-by-BHRS
Page 2 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish an article on avoiding and recognising atrio-oesophageal fistula in the winter newsletter circulated to members.

Verbatim wording from the response

“• BHRS will include an article on avoidance and recognition of atrio-oesophageal fistula in its winter newsletter which is circulated to all BHRS members in January and remind its members to ensure this complication is recorded in the national cardiac rhythm management database for which BHRS and the National Institute for Cardiovascular Research (NICOR) are responsible.”

Source location

2014-0479-Response-by-BHRS
Page 2 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

There is no evidence that newer ablation technologies or oesophageal temperature monitoring significantly reduce atrio-oesophageal fistula occurrence.

Verbatim wording from the response

“Procedural considerations include an awareness of the risk of this complication, reduction / titration and location of energy delivered. However, there is no evidence that newer ablation technologies or other strategies such as oesophageal temperature monitoring, make a significant difference to the occurrence of this complication. Operators should be aware that they need to limit the amount of ablation that takes place to the posterior wall of the left atrium and be aware of the possibility of this complication. BHRS believes that colleagues who perform this procedure are aware of this complication and take appropriate steps to reduce the likelihood of its occurrence.”

Source location

2014-0479-Response-by-BHRS
Page 1 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operators are aware of atrio-oesophageal fistula risk and take appropriate steps to reduce its occurrence.

Verbatim wording from the response

“Procedural considerations include an awareness of the risk of this complication, reduction / titration and location of energy delivered. However, there is no evidence that newer ablation technologies or other strategies such as oesophageal temperature monitoring, make a significant difference to the occurrence of this complication. Operators should be aware that they need to limit the amount of ablation that takes place to the posterior wall of the left atrium and be aware of the possibility of this complication. BHRS believes that colleagues who perform this procedure are aware of this complication and take appropriate steps to reduce the likelihood of its occurrence.”

Source location

2014-0479-Response-by-BHRS
Page 1 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Department of Health will contact appropriate bodies, such as the British Cardiology Society, regarding actions to be taken.

Verbatim wording from the response

“While I was sorry to read of Mrs Higham’s death, this case is not something that Public Health England can directly assist with. However, I understand that you have written to the Department of Health, who will contact appropriate bodies on your behalf, such as the British Cardiology Society. The Department will be in touch with you in due course to inform you of the actions to be taken.”

Source location

2014-0479-Response-by-Public-Health-England
Page 1 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The matter is not something Public Health England can directly assist with.

Verbatim wording from the response

“While I was sorry to read of Mrs Higham’s death, this case is not something that Public Health England can directly assist with. However, I understand that you have written to the Department of Health, who will contact appropriate bodies on your behalf, such as the British Cardiology Society. The Department will be in touch with you in due course to inform you of the actions to be taken.”

Source location

2014-0479-Response-by-Public-Health-England
Page 1 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The British Cardiovascular Society is best placed to respond to concerns about atrial-oesophageal fistula and circulate guidance to relevant surgeons.

Verbatim wording from the response

“The SCTS suggested that both cardiologists and electro-physiologists, through the BCS, were best placed to respond to your concerns and suggested that BCS could prepare a letter to be circulated to the upper gastrointestinal surgeons, thoracic surgeons and cardiac surgeons.”

Source location

2014-0479-Response-by-Department-of-Health
Page 2 · response
Published 3 November 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Remind members to record atrio-oesophageal fistula in the national cardiac rhythm management database.

    Stated by British Heart Rhythm SocietyStated plannedThe respondent said that this action was planned when they made their response on 3 November 2014.
  2. 2

    Send copies of the coroner’s letter and the response to the BCS and RCS.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 3 November 2014.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remind members to record atrio-oesophageal fistula in the national cardiac rhythm management database.

Verbatim wording from the response

“• BHRS will include an article on avoidance and recognition of atrio-oesophageal fistula in its winter newsletter which is circulated to all BHRS members in January and remind its members to ensure this complication is recorded in the national cardiac rhythm management database for which BHRS and the National Institute for Cardiovascular Research (NICOR) are responsible.”

Source location

2014-0479-Response-by-BHRS
Page 2 · response
Published 3 November 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Send copies of the coroner’s letter and the response to the BCS and RCS.

Verbatim wording from the response

“A copy of your letter and our response will be sent to the BCS. I trust they will take the opportunity to respond to you directly about this issue.”

Source location

2014-0479-Response-by-Department-of-Health
Page 2 · response
Published 3 November 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026