“(brief summary of matters of concern) Mr Tomlinson had a history of heart valve surgery…”
Dated 6 Mar 2026, from the coroner for Gwent. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 1 May 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated6 Mar 2026
- Deadline1 May 2026
- Published on judiciary.uk10 Mar 2026
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health Board | Response publishedPublished on judiciary.uk in March 2026. |
The coroner’s concerns
(brief summary of matters of concern) Mr Tomlinson had a history of heart valve surgery and was fitted with a new pacemaker in May 2023. The device was reviewed periodically at the Cardiac Device Clinic at the Regulation 28 – After Inquest Document Template Updated 30/07/2021 University Hospital of Wales. In the months after implantation, the pacemaker showed progressively increasing ventricular thresholds. At his review on 8 January 2024, the threshold was 5.0 V @ 2 ms and the predicted battery life had fallen to 10 months. Although he was well known to the physiologists and was visibly unwell, with marked weight loss, no record was made of his clinical condition. Evidence from a consultant cardiologist confirmed that the elevated threshold required referral to the Cardiology Department, but no referral was made. I found that the pacemaker itself did not cause Mr Tomlinson’s death from untreated infective endocarditis. However, a timely referral to cardiology would probably have led to earlier diagnosis, and the delay was likely to have contributed to his death. Evidence from the Chief Physiologist identified wider concerns within the service, including: 1. Lack of guidance on when pacemaker data should trigger cardiology review; 2. Limited physiologist knowledge of infective endocarditis; 3. Inconsistent gathering of clinical information and implant site checks during clinic visits; 4. How clinical findings were documented and communicated, particularly to the Cardiology team.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0131
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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