Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0131, written 6 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Mar 2026 |
|---|---|
| Reference | 2026-0131 |
| Deceased | Alan Tomlinson |
| Coroner | Martin Lanchester |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive of Cardiff and Vale University Health Board 1 CORONER I am Martin LANCHESTER, Assistant Coroner for the coroner area of Gwent 2 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. 3 INVESTIGATION and INQUEST On 14 May 2024 I commenced an investigation into the death of Alan Bevis TOMLINSON aged 55. The investigation concluded at the end of the inquest on 24 February 2026. Alan Tomlinson died on the 18 April 2024 at his home, from the effects of untreated infective endocarditis likely caused by a longstanding soft tissue infection at the site of a pacemaker implant which was implanted in May 2023. Mr Tomlinson’s developing Infective Endocarditis was not identified by his treating general practitioners and this was likely to have contributed to his death. Mr Tomlinson’s pacemaker had been noted to be defective in January 2024 but he was not referred to the Cardiology department at University of Wales Hospital and this also was likely to have contributed to his death. 4 CIRCUMSTANCES OF THE DEATH On 16th April 2024 Alan Bevis TOMLINSON attended at the University Hospital (UHW) Cardiff as he felt unwell and had swelling around the site of his pacemaker. Alan had been unwell for several months and had suffered significant weight loss and was anaemic. Alan had a new pacemaker fitted in May 2023 and he had not been well since this was changed. On arrival at the UHW Alan was told that he had swelling around the site of his pacemaker and needed to be admitted to a cardiac ward for further investigation and treatment. Alan was advised to return to his home address as there was no cardiac bed available. Alan died at his home address on the 18th April 2024. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (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: Lack of guidance on when pacemaker data should trigger cardiology review; 1. Limited physiologist knowledge of infective endocarditis; 2. 3. Inconsistent gathering of clinical information and implant site checks during clinic visits; 4. Cardiology team. How clinical findings were documented and communicated, particularly to the 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 01, 2026. I, the coroner, may extend the period. 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 Family Members And Next Of Kin I have also sent it to Not Applicable who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 06/03/2026 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Martin LANCHESTER Assistant Coroner for Gwent Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Woodland House
Maes-y-Coed Road
Cardiff
CF14 4HH
Ty Coedtir
Ffordd Maes-y-Coed
Caerdydd
CF14 4HH
29th April 2026
Coroner: Mr Martin Lanchester, Assistant Coroner for Gwent
Dear Mr Lanchester
Thank you for your Regulation 28 Report of 6th March 2026, issued following the inquest into
the death of Mr Alan Bevis Tomlinson. On behalf of Cardiff and Vale University Health Board,
I wish to extend our sincere condolences to Mr Tomlinson’s family for their loss. We recognise
the purpose of your report is to prevent future deaths, and we welcome the opportunity to
outline the actions we have taken and those we will be taking in direct response to the
concerns you identified.
1. Summary of the Concerns Raised
We note and accept the concerns set out in your Report, including:
• Lack of clear guidance on thresholds or criteria for referring pacemaker data for
cardiology review.
• Limited physiologist knowledge of infective endocarditis and its association with device
•
infections.
Inconsistent gathering of clinical information and examination/documentation of
implant sites during clinic visits.
• Variability in communication and documentation practices, particularly regarding
escalation to the Cardiology team.
We acknowledge the link you identified between the absence of timely referral and the delay
in diagnosing Mr Tomlinson’s evolving infective endocarditis.
Actions
The Health Board takes these findings extremely seriously. In response, the following actions
have already been implemented:
Immediate Clinical Review and Strengthened Referral Criteria
• A revised escalation and referral protocol has been implemented within the Cardiac
Device Clinic.
• A mandatory referral trigger is now in place if a device has lost a twofold safety margin.
This has been clearly documented in the “Managing the Unwell Patient Standard
Operating Procedure” (attached) which is stored on the departmental SharePoint.
• The Standard Operating Procedure has been shared with all Physiologists and will be
presented at the departmental Quality and Safety meeting on the 13th of May.
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Enhanced Clinical Assessment Standards
• A new history sheet has been developed for the documentation of all clinical findings
during Device Check clinic appointments. This requires.
o Documented assessment of the patient’s general condition, including the Red
Flag questions of any significant weight loss, any fevers, any changes to
mobility, any difficulty with speech, and any breathing difficulties.
o Mandatory inspection of the device implantation site and recording if presence
of any redness, swelling, heat, or threatened erosion.
• Monthly notes audits will be conducted for the quarter following presentation of the
SOP on the 13th of May.
Training and Education for Physiologists
• Training sessions have been arranged for delivery covering:
o Recognition of infective endocarditis, including atypical presentations, will be
delivered by a Consultant Cardiologist
o Recognising the generally unwell patient and Red Flags which will be delivered
by the Nursing Practice Educators
o When and how to escalate to a cardiologist has been circulated via e-mail and
will be delivered on the 13th of May Quality and Safety afternoon.
Strengthened Documentation and Communication Pathways
• All clinic entries now require explicit documentation of clinical findings, including
implant site, any red flags and symptom information provided by the patient, as well as
all device data and associated tests performed.
• The development of specific Cardiac Physiology inboxes in the existing e-Advice
system.
Development of a Standard Operating Procedure (SOP)
We have finalised a comprehensive SOP for device the escalation of the unwell patient,
covering.
Audit and Quality Assurance
• Audits of the following have been instigated:
o Notes Standards compliance
o E-Advice usage and response times
Digital Support
We are implementing the Fysicon system, which is an electronic patient record. This will
incorporate all clinical notes and will provide trend data to further enhance the clinical decision
making and improve patient outcomes.
Engagement With Staff and Wider Learning
The findings of the inquest and your Regulation 28 report have been:
• Shared with the Cardiology Directorate, Clinical Board leadership, and Quality & Safety
Committee.
To develop these service improvements benchmarking exercises were conducted. The
development of the Red Flag questions is a change to practice in Wales. On discussion with
our colleagues in neighbouring health boards, it appears the undergraduate Cardiac
Physiology teaching on recognition of systemic illness in patients is limited. The questions in
device clinics remain focused on cardiology specific conditions, such as heart failure. As a
Health Board, we recognise that this would be too limited for our patient cohort. We have,
therefore, developed broader Red Flag questions and an associated training package.
We recognise the seriousness of the failings identified and are committed to ensuring that the
lessons from this tragic case led to sustained, measurable improvement in our services. We
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
will continue to monitor compliance, strengthen training, and enhance our clinical pathways to
prevent similar harm.
Please be assured of our full cooperation and our commitment to implementing the actions
outlined. Should you require any further information or clarification, we would, of course, be
happy to provide this.
Yours sincerely
Chief Executive
Enc Managing the Unwell Patient SOP
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
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