Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0583, written 17 Nov 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Nov 2025 |
|---|---|
| Reference | 2025-0583 |
| Deceased | Thomas Morrell |
| Coroner | Thomas Crookes |
| Coroner area | Newcastle and North Tyneside |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | York and Scarborough Teaching Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Newcastle and North Tyneside Miss Georgina Nolan HM SENIOR CORONER Civic Centre , Barras Bridge , Newcastle Upon Tyne , NE1 8QH REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 17 November 2025 THIS REPORT IS BEING SENT TO: York and Scarborough Teaching Hospitals NHS Foundation Trust CORONER I am Thomas Crookes, Assistant Coroner for the area of Newcastle and North Tyneside. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 1 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 9 December 2024 I commenced an investigation into the death of Thomas Colin MORRELL. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Thomas Colin Morrell died from recognised complications from a necessary surgical procedure (heart transplantation). There may have been opportunities to intervene at an earlier juncture prior to him reaching end stage heart failure. However, it cannot be said more likely than not that this would have made a difference to the ultimate outcome. 3 The medical cause of death was; 1a Primary Graft Failure 1b Cardiac Transplantation 1c Hypertrophic Obstructive Cardiomyopathy II Ischaemic Stroke CIRCUMSTANCES OF THE DEATH 4 Thomas Colin Morrell had a longstanding history of hypertrophic obstructive cardiomyopathy (HOCM) for which he was due to have a re-ablation procedure on 18 October 2024. However, prior to this occurring, he was admitted to Scarborough Hospital's Accident and Emergency department on 08 October 2024 where he was initially treated for abdominal issues but was subsequently found to be in heart failure. He was transferred to the Freeman Hospital, Newcastle upon Tyne on 15 October 2024 where he was supported with ECMO and then biventricular support before heart transplantation became possible on 23 November 2024. This procedure was complicated by massive bleeding and require a massive blood transfusion. This adversely affected the new heart which arrested and its ability to contract was irreversibly compromised. Despite ECMO support, his heart function did not improve and Thomas Colin Morrell was found to have sustained neurological injury too. Support was withdrawn and Thomas Colin Morrell died on 3 December 2024 at the Freeman Hospital, Newcastle upon Tyne as a result of the failure of the heart transplant. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Following Mr Morrell's emergency admission to Scarborough Hospital on 8 October 2024, heart failure (as opposed to abdominal issues) played a greater role in his deterioration than was initially recognised by the treating clinicians. Had this been recognised sooner, Mr Morrell could have been transferred to the Freeman Hospital more quickly. There was not a standard operating process in place for Hypertrophic Obstructive Cardiomyopathy (HOCM) patients covering when to refer patients in such circumstances. 5 impairment (2) In 2019 an echocardiogram showed no changes to Mr Morrell's heart but by 6 July 2021 a cardiac MRI scan showed focal hypertrophy and patchy scarring within the heart, with to moderate range. On 16 October 2024 an functional in echocardiogram showed severe biventricular / echocardiograms undertaken between those dates to check for deterioration. Had the deterioration been detected sooner, I was told in evidence that there may have been an earlier opportunity to intervene prior to deterioration into end stage heart failure, which may have improved the prospects of surgical intervention. failure. There were no scans the mild ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you / your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 January 2026. I, the coroner, may extend the period. 7 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (mother of the deceased). I have also sent it to the Newcastle Upon Tyne Hospitals NHS Foundation Trust who may find it useful (partner of the deceased) and or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 17 November 2025 9 Signature Thomas Crookes, Assistant Coroner for the area of Newcastle and North Tyneside
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Medical Governance
The York Hospital
Wigginton Road
YORK
YO31 8HE
13 January 2026
Mr Thomas Crookes
Assistant Coroner for the area of Newcastle and North Tyneside
Dear Sir
Thank you for raising your concerns following the inquest surrounding the death of Mr
Thomas Morrell following his treatment at Scarborough Hospital. York & Scarborough
Teaching Hospitals NHS Foundation Trust (the Trust) recognises the seriousness of your
concerns outlined at Section 5 of the Report to Prevent Future Deaths (PFD). Following
further review of this case I write to outline our response to your concerns.
In response to your first matter of concern, Mr Morrell’s urgent admission was atypical, with
concerns of infection in the abdomen. Abdominal imaging and review by abdominal
specialists could not rule out an infective process. Intravenous antibiotics were utilised. On
cardiology review, heart failure was thought to be a major contributor, and appropriate
management commenced.
Intra-abdominal infection is an absolute contra-indication to heart transplantation and this
important differential, whilst delaying definitive management, was vital to fully investigate and
manage him appropriately.
We recognise that timely referral of appropriate patients to a transplant centre is an important
step in management and have circulated this message to relevant clinicians. We have a well-
established working relationship with the transplant centre in Newcastle including open
communication on cases where we have concerns. For example, as part of this relationship,
members of the Newcastle team presented to our cardiology governance meeting in autumn
2025.
In response to your second matter of concern, Mr Morrell was treated on a number of
occasions for symptoms of heart failure caused by atrial fibrillation since 2020. Each
decompensation was due to an onset of fibrillation and resolved by rhythm control. More
definitive management of rhythm control with AV nodal ablation had been planned for October
2024, the reason for this was due to a deterioration in his symptoms. Unfortunately, Mr Morrell
was admitted as an emergency, one week prior to this elective treatment.
Consideration of heart transplantation would require that the major treatable causes of heart
failure are properly addressed prior. Heart function at echocardiography does not drive the
need for heart transplantation, rather the ongoing symptom level once optimal therapy is in
place would be the driver to consider heart transplant. As such echocardiography showing a
deterioration in the function of the left ventricle on its own would not have prompted
consideration of heart transplant. Mr Morrell was still undergoing optimisation of therapy,
hence urgent referral for transplant assessment would not have materially advanced his
management.
On further review when drafting this response, it was noted that Mr Morrell did in fact have an
echocardiogram on 1/8/22, which showed improved heart function with an ejection fraction of
53%.
Conclusion
We hope that this information provides you with assurance that Mr Morrell’s management was
appropriate and that the Trust has reviewed your concerns thoroughly.
Yours faithfully
Medical Director & Responsible Officer
2
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