Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0142, written 10 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 | 10 Mar 2026 |
|---|---|
| Reference | 2026-0142 |
| Deceased | Jennine Romeo |
| Coroner | Alison Hewitt |
| Coroner area | City of London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Re : JENNINE SASHA ROMEO DECEASED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. University Hospital Medical Director of the North Middlesex , Chief Medical Director of the Royal Free London NHS Foundation Trust 1 CORONER I am Alison Hewitt, HM Senior Coroner for the City of London. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST I commenced an investigation into the death of Jennine Sasha Romeo on the 4th June 2025. The investigation concluded at the end of the inquest on the 10th March 2026. The conclusion of the inquest was that the medical cause of death was – Ia Multi Organ Failure Ib Dehiscence of prosthetic mitral valve (Operated on 23.5.25 with re-do sternotomy and mitral valve replacement) Ic Mitral valve regurgitation (Operated on 27.3.24 with mechanical mitral valve replacement) and my conclusion as to the death was that the Deceased, “Died as a result of post-operative complications of surgery performed to treat naturally occurring disease and post-operative complications of subsequent re-do surgery”. 4 CIRCUMSTANCES OF THE DEATH Jennine Romeo suffered mitral valve prolapse and severe mitral regurgitation and, on the 27th March 2024 at St. Bartholomew's Hospital, London, she underwent mechanical mitral valve replacement surgery which was completed without complication. Post-operatively, she was reviewed by the cardiac rehabilitation and valve clinics at the North Middlesex University Hospital. A transthoracic echocardiogram performed in August 2024 showed a well seated prosthetic valve with a trivial leak, and a transthoracic echocardiogram performed in January 2025 showed a well seated prosthetic valve with a mild leak, as well as a newly dilated and impaired right ventricle with severe tricuspid regurgitation and pulmonary hypertension. The January 2025 result was due to be reviewed by the valve clinic, but the Deceased's out patient appointments for February and for March 2025 were cancelled by the hospital, and there is no evidence of any clinical review of the result until May 2025. On the 7th April 2025, the Deceased was reviewed in the cardiac rehabilitation clinic and was found to be breathless on exertion and she was referred to the heart failure team for treatment; on further review on the 30th April 2025, tests revealed acute kidney and liver injuries and she was admitted urgently. A transthoracic echocardiogram performed on the 1st May 2025 showed a dehisced mitral valve and severe paravalvular leak with acute cardiac decompensation. She was transferred to St. Bartholomew's Hospital's intensive treatment unit in a critical condition. Following some improvement, the Deceased underwent challenging and high-risk re-do sternotomy and further mitral valve replacement surgery on the 23rd May 2025. Post-operatively, she was stable, and appeared to be improving, until the 27th May 2025 when there was rising lactate and decreasing urine output. On the 28th May 2025, the Deceased was taken to theatre to drain pericardial effusion but she suffered a cardiac arrest during induction of anaesthesia, necessitating cardiopulmonary bypass and re-sternotomy. The Deceased was resuscitated from this and a subsequent arrest but, despite full support in the intensive treatment unit, she subsequently developed multiorgan failure from which she died on the 29th May 2025. The delay in clinical review of the January 2025 transthoracic echocardiogram result led to a delay in the discovery of the valve dehiscence. Timely review would probably have resulted in further investigations and earlier diagnosis of the dehiscence progression, earlier escalation to the surgical team at St. Bartholomew's Hospital, and earlier surgery. If surgery had been performed prior to the Deceased's significant deterioration in April 2025, there may have been a different outcome. 5 CORONER’S CONCERNS In the course of the inquest the evidence 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: 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. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 6th May 2026. I, as 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 should explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner, to the following Interested Persons and to the other organisations listed below which may find it useful or of interest: a. The parents of Jennine Romeo b. Barts Health NHS Trust I am also under a duty to send the Chief Coroner a copy of your response. I may also send a copy of your response to any other 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. 10th March 2026 Alison Hewitt
2 responses 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.
North Middlesex University Hospital Alison Hewitt HM Senior Coroner for City of London City of London Coroner’s Court 4th Floor Central Criminal Court Old Bailey London Dear Coroner, North Middlesex University Hospital Sterling Way London N18 1QX 28th April 2026 (typo amended 14th May 2026) Re: Prevention of Future Deaths Report – Ms Jennine Romeo who died on 29th May 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th March 2026 concerning the death of Ms Jennine Romeo on 29th May 2025. In advance of responding to the specific matters of concerns raised in your Report, I would like to express my deep condolences to Ms Romeo’s family and loved ones. North Middlesex University Hospital is keen to assure the family and yourself that the areas raised as part of the evidence at the Inquest have been listened to and reflected upon. Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks. The pathway outlines how to escalate, including appropriate email contacts for administrative purposes. The escalation pathway is shared with the cardiac physiologist team and discussed in team meetings to ensure the team are up to date with current pathway. The escalation pathway is reviewed on an annual basis by the departments lead clinicians/physiologist or earlier if the need arises from specific cases. Your Report raised a concern regarding learning points and action taken following the Hospital’s own Mortality Review which took place as part of the Cardiology department’s monthly governance meeting on 10th September 2025. The learning points from that meeting were as follows: www.royalfree.nhs.uk Peter Landstrom, Group Chief Executive North Middlesex University Hospital North Middlesex University Hospital Sterling Way London N18 1QX Paravalvular leaks may present subtly and evolve gradually; TOE should be considered early if there is any uncertainty. Right ventricular dilatation and dysfunction are important prognostic and surgical risk markers and should always be factored into decision-making. Surgical operative notes should be accessible to imaging and heart failure teams to improve interpretation and continuity of care. Cases with uncertainty or diagnostic challenge should be escalated for senior review, with a low threshold for MDT discussion. Regular reinforcement, reminders, and refreshers on the recognition of paravalvular leaks should form part of ongoing departmental education. Learning points from individual cases are discussed in the departmental weekly MDT echo meeting, and in the case of Ms. Romeo the challenges of assessing mechanical valves as well as abnormal change to parameters that one should be aware and need to escalate have been discussed and shared with the wider cardiac physiology team. There are also departmental educational sessions that specifically focus on assessment of valve disease. With regards to specific changes to the escalation pathway following Ms. Romeo’s case, the escalation criteria have been reviewed and an additional criterion, detailing the findings of new pulmonary hypertension have been included in the pathway. Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary. This aims to ensure consistent decision-making, reduce the risk of repeated cancellations, and improve patient pathway management. Yours sincerely, Medical Director www.royalfree.nhs.uk Peter Landstrom, Group Chief Executive
North Middlesex University Hospital Alison Hewitt HM Senior Coroner for City of London City of London Coroner’s Court 4th Floor Central Criminal Court Old Bailey London Dear Coroner, North Middlesex University Hospital Sterling Way London N18 1QX 28th April 2026 Re: Prevention of Future Deaths Report – Ms Jennine Romeo who died on 4th June 2025 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th March 2026 concerning the death of Ms Jennine Romeo on 4th June 2025. In advance of responding to the specific matters of concerns raised in your Report, I would like to express my deep condolences to Ms Romeo’s family and loved ones. North Middlesex University Hospital is keen to assure the family and yourself that the areas raised as part of the evidence at the Inquest have been listened to and reflected upon. Your Report raised a concern regarding the lack of system in place to escalate and review abnormal findings on transthoracic echocardiogram. We can assure you that the echocardiography department has an established escalation pathway and protocol on how to action significant abnormal results. The escalation protocol (attached as Appendix 1) has been operational since 2019 with criteria based on best practice and guidelines from the British Society for Echocardiography and includes significant valvular abnormalities, ventricular abnormalities, large pericardial collections, markedly enlarged vessels, abnormal masses and other miscellaneous findings. The pathway clearly outlines the action of escalation which, depending on the findings, will include either on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks. The pathway outlines how to escalate, including appropriate email contacts for administrative purposes. The escalation pathway is shared with the cardiac physiologist team and discussed in team meetings to ensure the team are up to date with current pathway. The escalation pathway is reviewed on an annual basis by the departments lead clinicians/physiologist or earlier if the need arises from specific cases. Your Report raised a concern regarding learning points and action taken following the Hospital’s own Mortality Review which took place as part of the Cardiology department’s monthly governance meeting on 10th September 2025. The learning points from that meeting were as follows: www.royalfree.nhs.uk Peter Landstrom, Group Chief Executive North Middlesex University Hospital North Middlesex University Hospital Sterling Way London N18 1QX Paravalvular leaks may present subtly and evolve gradually; TOE should be considered early if there is any uncertainty. Right ventricular dilatation and dysfunction are important prognostic and surgical risk markers and should always be factored into decision-making. Surgical operative notes should be accessible to imaging and heart failure teams to improve interpretation and continuity of care. Cases with uncertainty or diagnostic challenge should be escalated for senior review, with a low threshold for MDT discussion. Regular reinforcement, reminders, and refreshers on the recognition of paravalvular leaks should form part of ongoing departmental education. Learning points from individual cases are discussed in the departmental weekly MDT echo meeting, and in the case of Ms. Romeo the challenges of assessing mechanical valves as well as abnormal change to parameters that one should be aware and need to escalate have been discussed and shared with the wider cardiac physiology team. There are also departmental educational sessions that specifically focus on assessment of valve disease. With regards to specific changes to the escalation pathway following Ms. Romeo’s case, the escalation criteria have been reviewed and an additional criterion, detailing the findings of new pulmonary hypertension have been included in the pathway. Your report raised a concern regarding review of clinical results in a timely manner, whether or not the planned outpatient appointment takes place. Following this a revised process has been introduced to strengthen oversight of appointment cancellations. This has been operational since April 2026. If a patient has their appointment cancelled (by either the service, or patient) they are automatically booked into the next available follow-up appointment slot by the bookings team. If a patient has had their appointment previously cancelled by the service, where it is identified that their next appointment would also be cancelled, the case is escalated to the Cardiology service manager for senior review. The case is then discussed with the relevant clinicians to determine the most appropriate course of action and minimise delay in clinical review where necessary. This aims to ensure consistent decision-making, reduce the risk of repeated cancellations, and improve patient pathway management. Yours sincerely, Medical Director www.royalfree.nhs.uk Peter Landstrom, Group Chief Executive
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