“As stated above, the evidence suggested that the outcome of a transthoracic…”
Dated 10 Mar 2026, from the coroner for City of London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 5 May 2026. A reply may have been sent and not yet published.
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.
- Report dated10 Mar 2026
- Deadline5 May 2026
- Published on judiciary.uk12 Mar 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Middlesex University Hospital NHS TrustNamed in the report as “North Middlesex university Hospital” | Response publishedPublished on judiciary.uk in March 2026. |
| Royal Free London NHS Foundation Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 5 May 2026. A reply may have been sent and not yet published. |
The coroner’s concerns
As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital. There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned. Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team. Although the Hospital’s own Mortality Review highlighted a number of learning points, I was not told of any action which has been taken in response to those matters as yet. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisations have the power to take such action.
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, 2026-0142
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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