“Concern 1 1”

The coroner’s concerns

Concern 1 1. Although the need for pacemaker lead extraction at some point was recognised by 2019 at the latest, and although the procedure would necessarily be performed in a tertiary centre, no tertiary centre was consulted or involved in relevant care planning prior to the Deceased’s death; there was no such involvement in 2021, when a decision was made to change the pacemaker battery but not the leads, and there was no such involvement subsequently, as the Deceased’s condition deteriorated. 2. The evidence I heard from St. Bartholomew’s Hospital was that it is important that the tertiary centre is aware of such patients at any early stage, as this provides an opportunity for the specialist team to understand fully the patient’s precise situation, and to plan for an elective procedure to be performed in a timely manner. I heard that the team at St. Bartholomew’s Hospital has such early involvement with the hospitals from which referrals are routinely received (which does not include the William Harvey Hospital). 3. I am concerned that the lack of timely involvement of the relevant tertiary centre in care planning may result in future deaths. Concern 2 4. Further, at the inquest, concern was expressed by the Deceased’s family that she was not fully informed and consulted on the question of when the required lead extraction procedure should be performed. There was clear evidence that by late 2024, her condition had deteriorated significantly and that she later expressed her wish to undergo the procedure as soon as possible. There does not appear to be any system in place to ensure that, when it is recognised that a procedure will be needed at some point, the patient is fully involved in the decision making as to when it is performed. Concern 3 5. The Deceased’s critical test result, which was available from the 31 st December 2024, was not accessed by the responsible consultant until March 2025. Further, the decision made subsequently, on the 3rd April 2025, to refer for lead extraction was not acted upon and no referral was made. It is not appropriate for concerns about the clinician to be addressed by means of this PFD Report. However, the failures raise concern also for the systems in place in the William Harvey Hospital. First, in evidence, the clinician suggested that she had not been provided by the Trust with sufficient time in which to perform these tasks and that she was overwhelmed by receiving an unnecessary number of communications. Secondly, I was told that there was no system in place to check that test results have been accessed and read or to alert clinicians to test results which had not been accessed and read, whether through IT alerts or otherwise. Thirdly, it seems that there is no system in place to check that important tasks (such as making a patient referral) have been performed and/or to identify when they have not been performed within a reasonable period. Concern 4 6. Given the seriousness of the omissions by the responsible consultant, which were apparent from her witness statement provided to me in advance of the inquest, I am concerned that the William Harvey Hospital and the Trust did not undertake, prior to the inquest, any internal investigation or review of its care and management of the Deceased, whether by means of a mortality review or otherwise. 7. I am concerned that an absence of a system to ensure that serious omissions are investigated and reviewed, independently of the inquest process, will result in failures to make necessary improvements for patient safety and thereby the risk of future deaths. 10. COPIES AND PUBLICATION OF THIS REPORT: I have a duty to send a copy of my report to every Interested Person who, in my opinion, should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. The Family of Kerry Teresa Singh 2. Barts Health NHS Trust I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE: Alison Hewitt

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, 2026-0314

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