Alan Tomlinson
6 Mar 2026 · Coroner Martin Lanchester · Gwent
The coroner's concerns
1. delayed referral to cardiology
“The device was reviewed periodically at the Cardiac Device Clinic at the University Hospital of Wales”
2. inconsistent clinical information gathering
“Lack of guidance on when pacemaker data should trigger cardiology review”
3. missed diagnosis of infective endocarditis
“Limited physiologist knowledge of infective endocarditis”
4. incomplete clinical assessment
“Inconsistent gathering of clinical information and implant site checks during clinic visits”
5. poor communication of clinical findings
“How clinical findings were documented and communicated, particularly to the Cardiology team”