Kerry Singh

Trust Offices 
Kent & Canterbury Hospital 
Ethelbert Road 
Canterbury 
Kent  
CT1 3NG 

Alison Hewitt 

HM Senior Coroner for the City of London  

Sent by email  

   13 August 2026 

Dear Ma’am,  

Regulation 28 – Prevention of Future Deaths (PFD) Response regarding the inquest into the 
death of Kerry Singh 

This is the formal response on behalf of East Kent Hospitals University NHS Foundation Trust (“the 
Trust”) to the Prevention of Future Deaths report issued following the inquest into the death of Mrs 
Kerry Singh dated 25 June 2026. 

The Trust has carefully considered each concern and taken appropriate action.  

Concern 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. 
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). 

I am concerned that the lack of timely involvement of the relevant tertiary centre in care planning 
may result in future deaths. 

   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Trust response 

The  Trust  recognises  the  importance  of  ensuring  that  complex  cardiac-device  cases  are 
identified promptly and, where appropriate, discussed with or referred to a specialist tertiary 
centre at an early stage. 

The Trust Cardiology Service has a well-established Devices MDT through which complex 
device  cases  are  reviewed.  The  MDT  is  responsible  for  identifying  patients  in  whom  lead 
extraction, lead revision or another specialist intervention may need to be considered and, 
where appropriate, seeking advice from or making a referral to a specialist tertiary centre. 

Following the inquest into Mrs Singh’s death, the Terms of Reference for the Devices MDT 
were formally reviewed and ratified. A Standard Operating Procedure (“SOP”) has also been 
developed and implemented. 

The  revised  governance  documents  define  the  purpose  and  scope  of  the  MDT, 
responsibilities of attendees, referral criteria, arrangements for recording clinical reasoning 
and communicating outcomes, circumstances in which tertiary advice should be sought, and 
the process for allocating, monitoring and escalating MDT actions. 

This governance model will also be applied, where appropriate, to other Cardiology Service 
MDTs. 

The Trust recognises that abnormal or deteriorating lead parameters do not invariably require 
lead  extraction.  Decisions  must  be  made  on  an  individual  basis,  taking  account  of  lead 
behaviour,  clinical  symptoms,  procedural  risk,  the  patient’s  overall  condition  and  the 
availability of alternative management strategies. 

The  purpose  of  the  strengthened  MDT  and  tertiary-referral  process  is  therefore  not  to 
mandate extraction. It is to ensure that complex cases are identified consistently, reviewed 
promptly  and,  where  appropriate,  discussed  with  a  specialist  extraction  centre  before  the 
clinical situation becomes urgent. 

Review of the 2021 decision 

Mrs Singh’s case was reviewed in detail at the Cardiology Service Governance Day on 14 
July 2026 as part of a multidisciplinary morbidity and mortality review.  The review involved 
33 members of the wider cardiology team and was multidisciplinary, with representation from 
medical, nursing, cardiac physiology and operational colleagues. 

The review concluded that the decision made in 2021 to replace the pacemaker generator 
without  replacing  or  extracting  the  leads  was  clinically  reasonable  on  the  information 
available at the time. 

At that stage, the lead findings had not demonstrated the subsequent pattern of deterioration 
seen  from  2024  onwards.  Continued  monitoring  and  device  optimisation  therefore 
represented a clinically defensible approach. 

The  review  nevertheless  identified  opportunities  to  strengthen  the  processes  surrounding 
such decisions, particularly by ensuring that the rationale for continued surveillance and the 
circumstances that would trigger reconsideration or tertiary advice are clearly documented, 
that MDT outcomes are uploaded promptly to the electronic patient record, and that actions 
arising from MDT discussion are allocated to a named individual and subsequently confirmed 
as completed. 

 
 
 
 
 
 
 
 
 
 
 MDT action tracking 

Although  actions  arising  from  MDT  discussions  were  historically  recorded  on  individual 
referral documentation, the Cardiology Service has now introduced a centralised MDT action 
log. 

The action log records the:  

patient and case discussed; 

a. 
b.  MDT decision; 
c. 
d. 
e. 
f. 
g. 

action required; 
person responsible for completing the action; 
target completion date; 
status of completion; and 
any requirement for escalation. 

Outstanding  actions  are  reviewed  at  the  subsequent  MDT  meeting  and  escalated  where 
necessary. 

Pending appointment of dedicated administrative support, interim arrangements have been 
put in place to ensure that the action log is maintained and reviewed. The Specialty Doctor 
who currently coordinates the Devices MDT provides clinical oversight, with administrative 
support contributing to the process where available. The proposed MDT Coordinator role is 
intended  to  provide  a  more  sustainable  arrangement  and  to  ensure  that  clinical  time  is 
focused appropriately on tasks requiring medical input. 

Administrative support 

The service has developed a job description for a dedicated Cardiology MDT Coordinator. 
The  proposed  role  would  support  the  administration  of  Cardiology  MDTs,  maintain  action 
logs,  monitor  completion  of  agreed  actions,  ensure  that  outcomes  are  uploaded  to  the 
electronic patient record and support audit of compliance with MDT processes. 

A business case is being prepared for consideration through the Trust’s financial-governance 
processes.  In  parallel,  the  Cardiology  Operations  Team  is  reviewing  existing  resources to 
determine whether funding can be identified through internal reallocation. 

The introduction of the action log and formal allocation of interim responsibility mean that the 
improvements described above are not dependent upon approval of the proposed post. 

Further case review 

As a further learning action, the Cardiology Service will undertake a multidisciplinary review 
of  Mrs  Singh’s  Emergency  Department  attendances  during  the  four  years  preceding  her 
death. 
The review will consider whether there were opportunities to: 

a. 
b. 
c. 
d. 
e. 

reassess her overall cardiac-device pathway; 
changes in her clinical condition; 
seek specialist advice; 
recognise reconsider the timing of tertiary referral; or 
improve  communication  and  coordination  between  the  teams  involved  in  her 
care. 

 
 
 
 
 
 
 
 The  review  will  be  completed  by  2nd  October  2026,  and  reported  to  the  Cardiology 
Governance Meeting in October 2026.  Any further recommendations will be recorded on the 
service governance action log, assigned to named individuals and monitored to completion. 

Concern 2 

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. 

Trust response 

The Trust recognises the importance of ensuring that patients are fully involved in decisions 
where a device or lead problem has been identified that may require future intervention. 

The final decision about whether and when to undertake extraction is made by the specialist 
extraction centre in consultation with the patient. The local Cardiology Service is, however, 
responsible for ensuring that the patient’s concerns and preferences are heard, documented 
and considered when determining whether specialist advice or referral is required. 

The revised Devices MDT SOP requires the clinical plan, where relevant, to document the 
rationale for continued monitoring, the potential future need for lead revision or extraction, 
circumstances that should trigger reconsideration or tertiary advice, the information provided 
to the patient, their questions and preferences, and the arrangements for follow-up. Where a 
patient  reports  worsening  symptoms,  expresses  significant  concern  or  wishes  to  pursue 
extraction, the case should be escalated for consultant review or discussion at the Devices 
MDT, with tertiary advice sought where appropriate. 

Cardiac physiologists and healthcare scientists remain responsible for assessing device and 
lead performance and optimising device programming within their scope of practice. Where 
optimisation  is  no  longer  sufficient,  lead  findings  deteriorate,  symptoms  may  be  device-
related, or significant patient concern is expressed, the case should be escalated through the 
agreed clinical pathway. 

Concern 3 

The  Deceased’s  critical  test  result,  which  was  available  from  the  31st  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. 

 
 
 
 
 
 
 Trust response 

The Trust recognises that the reliable management of abnormal results and important clinical 
actions requires a closed-loop process. Simply sending a result or communication to a named 
clinician  does  not,  by  itself,  provide  assurance  that  the  information  has  been  reviewed, 
acknowledged and acted upon. 

The  cardiac  physiology  service  has  an  established  SOP  governing  the  identification  and 
escalation  of  abnormal  findings.  Following  the  inquest,  this  is  being  revised  to  strengthen 
closed-loop  communication.  The  revised  process  will  require  abnormal  findings  to  be 
categorised according to clinical urgency and communicated through an agreed escalation 
route, identifying the nature and urgency of the finding, the action required and the timeframe 
for response. Where acknowledgement or an appropriate clinical response is not received 
within  the  specified  timeframe,  the  finding  will  be  escalated  to  an  alternative  consultant 
cardiologist or the on-call cardiology team according to clinical urgency. The communication 
and  resulting  clinical  action  will  be  documented  in  the  electronic  patient  record.  Where 
appropriate, the cardiac physiologist may also refer the patient directly to the Devices MDT. 

Actions agreed through the Devices MDT are now recorded on a central action log, with a 
named  responsible  individual  and  target  completion  date.  Outstanding  or  overdue  actions 
are  reviewed  through  the  MDT  process  and  escalated  where  necessary.  This  includes 
tertiary-centre  referrals,  investigations,  consultant  review,  changes  to  follow-up  and 
communication with patients. Where tertiary referral is agreed, completion is confirmed by 
evidence that the referral has been submitted and recorded. 

Consultant  cardiologists  have  programmed  time  within  their  job  plans  for  clinical 
administration,  including  review  of  results  and  correspondence,  making  referrals  and 
completing  associated  patient-care  tasks.  Individual  workload  and  job  plans  are  reviewed 
through the Trust’s established job-planning process. The Trust nevertheless recognises that 
the  provision  of  administrative  time  does  not  remove  the  need  for  reliable  systems  to 
distinguish  urgent  clinical  information  from  routine  communication  and  to  ensure  that 
important findings and actions are acknowledged and completed. 

The Cardiology Service will review implementation of the revised abnormal-results escalation 
process and compliance with the completion of Devices MDT actions through its established 
governance arrangements. 

Concern 4 

A)  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. 

B)  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. 

Trust response 

The Trust accepts the importance of ensuring that material patient-safety concerns identified 
during preparation for an inquest are considered through the Trust’s clinical-governance and 
patient-safety processes before the inquest takes place. 

 
 
 
 
 
 
 
 
 The Trust has established mechanisms for identifying and reviewing patient-safety concerns. 
These include mortality review following Medical Examiner scrutiny, patient-safety incident 
reporting, and concerns identified through complaints, inquests, claims, enquiries from other 
healthcare providers or other review processes. Within Cardiology, these arrangements are 
supported  by  morbidity  and  mortality  review,  pacing  and  device-complication  review, 
multidisciplinary  governance  meetings,  Structured  Judgement  Review  and  escalation 
through the Trust’s Patient Safety Incident Response Framework where appropriate. 

In Mrs Singh’s case, in the absence of a Medical Examiner review or a patient-safety incident 
report,  the  Trust  recognises  that  there  were  missed  opportunities  for  the  concerns 
subsequently identified at inquest to be referred for internal review. These included concerns 
arising through preparation of the witness evidence and the lack of follow-up after the Trust 
Patient  Safety  Team  received  a  request  for  further  information  from  St  Bartholomew’s 
Hospital to support its own patient-safety investigation. 

The Trust Patient Safety Incident Response Policy and Plan already recognise that inquest 
review and preparation may identify patient-safety issues and learning. In order to strengthen 
the practical application of this requirement, the Trust is reinforcing the expectation that staff, 
including clinical and legal services, report patient-safety concerns identified during inquest 
preparation or other review processes so that they can be considered through the appropriate 
governance route and a proportionate learning response determined. Relevant documents, 
including  witness  statements  where  appropriate,  will  be  made  available  within  the  risk-
management  system  to  support  patient-safety  review,  and  a  list  of  inquest  cases  will  be 
shared with and reviewed regularly by the Patient Safety Team. 

Material  clinical  concerns  identified  through  review  of  the  medical  record,  preparation  of 
witness  statements,  disclosure,  legal  advice,  expert  evidence, meetings with  witnesses  or 
correspondence  from  the  Coroner  or  family  will  therefore  be  referred  to  the  relevant 
governance  and  Patient  Safety  teams  for  documented  consideration.  The  response  may 
include  a  Structured  Judgement  Review,  multidisciplinary  case  review,  thematic  review, 
incident-review  process,  professional-governance  review  or  another  proportionate  form  of 
assurance. The decision and any resulting actions will be documented. 

Mrs Singh’s case was subsequently reviewed at the Cardiology Governance Day on 14 July 
2026. The review considered the clinical decisions relating to her pacemaker leads, the timing 
of tertiary-centre  involvement,  communication  of  abnormal findings,  patient  involvement  in 
decision-making, completion of agreed referrals and actions, and the governance processes 
that  operated before the inquest. The actions arising from that review are reflected in this 
response. 

The Trust will review the effectiveness of the strengthened interface between Legal Services, 
Divisional  Governance  and  the  Patient  Safety  Team  through  its  established  governance 
arrangements. 

Conclusion 

The  Trust  has  carefully  considered  the  concerns  raised  by  the  Coroner  and  has  undertaken  a 
detailed review of the relevant Cardiology Service processes. The Trust considers that the decision 
made in 2021 to replace Mrs Singh’s pacemaker generator without extracting or replacing the leads 
time. 
was 

reasonable 

information 

available 

clinically 

that 

the 

on 

at 

The  Trust  nevertheless  recognises  opportunities  to  strengthen  the  systems  surrounding  complex 
device management. Changes have been made to the Devices MDT and its governance, tertiary 

 
 
 
 
 
 
 
 
 referral and action tracking, communication and escalation of abnormal findings, documentation of 
patient involvement, and the interface between inquest preparation and patient-safety governance. 

These  arrangements  will  be  reviewed  through  established  Cardiology,  Divisional  and  Trust 
governance processes, with further learning and actions recorded and monitored to completion. The 
Trust hopes this provides assurance that the Coroner’s concerns have been taken seriously and that 
proportionate action has been taken to reduce the risk of similar events occurring in future. 

Yours sincerely 

Acting Chief Executive Officer