Jennine Romeo
10 Mar 2026 · Coroner Alison Hewitt · City of London
The coroner's concerns
1. delayed review of echocardiogram result
“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”
2. lack of result review system
“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,”
3. absence of flagging pathway for critical results
“no relevant pathway for the echocardiography team to flag a result such as this to the clinical team”
4. lack of response to learning points
“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”