A heart scan conducted at North Middlesex University Hospital was not reviewed quickly enough, reports Ben Lynch, Local Democracy Reporter

A woman who died of complications including multiple organ failure may have survived had the NHS trust administering her care reviewed a heart scan in a “timely manner”, a coroner has found.

Alison Hewitt, senior coroner for the City of London, concluded that had Jennine Romeo’s transthoracic echocardiogram result been assessed without delay further investigations and surgery may have been brought forward.

In a ‘prevention of future deaths’ report, Hewitt wrote: “If surgery had been performed prior to the deceased’s significant deterioration in April 2025, there may have been a different outcome.”

A spokesperson for Royal Free London NHS Foundation Trust, which was responsible for the scan and subsequent reviews, offered their condolences to Romeo’s family.

They added the trust has already taken steps to ensure heart scans are assessed quicker and abnormal findings reported immediately to a senior doctor.

Hewitt launched an investigation into Jennine’s death on 4th June last year, concluding at the end of the inquest on Tuesday, 10th March.

In the report, Hewitt wrote that Jennine underwent surgery at St Bartholomew’s Hospital on 27th March 2024 after suffering from mitral valve prolapse and severe mitral regurgitation.

She was then reviewed by the cardiac rehabilitation and valve clinics at the North Middlesex University Hospital in Edmonton, which since the start of 2025 has been run by Royal Free NHS Foundation Trust.

A transthoracic echocardiogram, or ultrasound of the heart, was completed in August 2024 with a second the following January.

Both revealed a “well seated prosthetic valve” with a trivial and later a mild leak. The latter scan also uncovered issues including pulmonary hypertension.

Hewitt wrote: “The January 2025 result was due to be reviewed by the valve clinic, but the deceased’s outpatient 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.”

Further complications were however discovered including on 30th April last year when tests revealed acute kidney and liver injuries.

Another transthoracic echocardiogram was performed on 1st May showing issues such as a dehisced mitral valve, meaning it has detached from the heart tissue, following which Jennine was transferred to St Bartholomew’s Hospital’s intensive treatment unit.

She was later operated on and appeared to be improving until 27th May, when she was found to have “rising lactate and decreasing urine output”.

Jennine was taken to theatre the following day but suffered a cardiac arrest.

Hewitt wrote: “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.”

In her report the coroner wrote that the delay in reviewing the January 2025 transthoracic echocardiogram result “led to a delay in the discovery of the valve dehiscence”.

She continued: “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.”

Jennine’s cause of death was listed as multi-organ failure, dehiscence of prosthetic mitral valve, and mitral valve regurgitation.

Hewitt raised concerns included that there appears to be no system to ensure such a result is viewed and considered “in a timely manner”, nor is there a pathway for the echocardiography team to flag a result to clinical colleagues.

Responding to the findings, a spokesperson for Royal Free London NHS Foundation Trust said: “We would like to share our deepest condolences with the family. Our thoughts are with them at this incredibly difficult time.

“We have already taken steps to ensure that heart scans are reviewed in a timely manner and any abnormal findings are immediately reported to a senior doctor. We will carefully consider all the points raised in the coroner’s report and will be providing her with a detailed response.”

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