Coroner Finds Delayed Heart Scan Review Could Have Prevented London Patient's Death
A coroner has concluded that a woman who died from complications including multiple organ failure might have survived if an NHS Trust had reviewed a critical heart scan in a timely manner. The findings point to significant lapses in patient care at a London hospital.
Systemic Failures in Cardiac Care
Alison Hewitt, HM Senior Coroner for the City of London, determined that Jennine Romeo's death could potentially have been avoided. In a prevention of future deaths report, Ms Hewitt stated that had Ms Romeo's transthoracic echocardiogram result been assessed without delay, further investigations and surgery might have been expedited.
"If surgery had been performed prior to the Deceased's significant deterioration in April 2025, there may have been a different outcome," Ms Hewitt wrote in her report.
Chronology of Medical Oversights
Ms Romeo underwent initial surgery at St Bartholomew's Hospital on March 27, 2024, for mitral valve prolapse and severe mitral regurgitation. She was subsequently monitored at North Middlesex University Hospital in Enfield, which is operated by the Royal Free London NHS Foundation Trust.
A transthoracic echocardiogram was performed in August 2024, followed by another in January 2025. The January scan revealed pulmonary hypertension and other issues, but it was not reviewed until May 2025, after Ms Romeo's outpatient appointments for February and March were cancelled by the hospital.
Critical delays in reviewing the scan results meant that complications, including a dehisced mitral valve where the prosthetic detached from heart tissue, were not discovered until Ms Romeo's condition had severely deteriorated.
Final Days and Cause of Death
On April 30, 2025, tests showed acute kidney and liver injuries. Another echocardiogram on May 1 confirmed the valve dehiscence, leading to Ms Romeo's transfer to St Bartholomew's Hospital intensive treatment unit.
Despite surgery and initial improvement, Ms Romeo suffered cardiac arrest on May 28 and was resuscitated, but she subsequently developed multiorgan failure and died on May 29, 2025. The official cause of death was listed as:
- Multi-organ failure
- Dehiscence of prosthetic mitral valve
- Mitral valve regurgitation
Coroner's Concerns and Trust Response
Ms Hewitt highlighted that there appears to be no system to ensure such scan results are viewed promptly, nor a clear pathway for the echocardiography team to flag abnormal findings to clinical colleagues.
A spokesperson for the Royal Free London NHS Foundation Trust offered condolences to Ms Romeo's family and stated that steps have already been taken to ensure heart scans are reviewed more quickly and abnormal findings are immediately reported to senior doctors. The Trust pledged to carefully consider all points in the coroner's report and provide a detailed response.
This case underscores ongoing challenges in NHS patient safety protocols and the critical importance of timely medical reviews in preventing tragic outcomes.
