10 Mar 2026 Jennine Sasha Romeo · Prevention of Future Deaths report City of London
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Concerns raised 2 Lack of a system ensuring timely review and consideration of echocardiography results View source Lack of a pathway for echocardiography teams to flag results to clinical teams View source
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Jennine Sasha Romeo · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jennine Sasha Romeo died on 29 May 2025 after developing multiorgan failure following complications of mitral valve surgery and subsequent re-do surgery. The January 2025 echocardiogram showing serious cardiac abnormalities was not clinically reviewed until May, after hospital outpatient appointments had been cancelled. The report identified concerns about the absence of systems to ensure timely review of results and a pathway for the echocardiography team to flag significant findings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring timely review and consideration of echocardiography results
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a pathway for echocardiography teams to flag results to clinical teams
Wider context from the report “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.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate and update the echocardiography escalation protocol, including senior review routes and a new criterion for pulmonary hypertension findings.
Verbatim wording from the response “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 an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations for senior clinical review.
Verbatim wording from the response “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.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatically book cancelled appointments into the next available follow-up slot and escalate repeated service cancellations to the Cardiology service manager for senior review.
Verbatim wording from the response “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.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate and annually review the echocardiography escalation pathway, including escalation of significant abnormalities and the added criterion for new pulmonary hypertension.
Verbatim wording from the response “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.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An established echocardiography escalation pathway and protocol adequately address significant abnormal findings.
Verbatim wording from the response “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 an on-call Cardiologist review on the day of the scan or a Cardiology Consultant review of results within 2 weeks.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An established echocardiography escalation pathway and protocol are considered sufficient to address significant abnormal findings.
Verbatim wording from the response “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.” Source location Response from North Middlesex University Hospital and the Royal Free Hospital
Open published response
6 Aug 2019 Joseph Arthur Charles · Prevention of Future Deaths report North London
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Concerns raised 1 Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Joseph Arthur Charles · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Arthur Charles fell at home, underwent right elbow surgery, was discharged, and was later found unresponsive in bed by his wife. The concern was that national guidance existed for preventing deep vein thrombosis and pulmonary embolus after lower-limb surgery but not after upper-limb surgery.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of recommendations or guidance for prevention of DVT and pulmonary embolus in upper limb surgery
Wider context from the report “That although there are clear National guidelines for the prevention of DVT and pulmonary embolus there are no such recommendations or guidance for upper limb surgery .
” Open source report
6 May 2016 Carole Rita Lovett · Prevention of Future Deaths report North London
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Concerns raised 4 Inadequate communication between staff at all levels View source Insufficient staff competence and training in use of the NEW Score system View source Failure to consider alternate forms of monitoring during continuous alarms View source Failure of monitoring equipment alarms to trigger senior staff attendance View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Carole Rita Lovett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Carole Rita Lovett, a patient under Section 3 of the Mental Health Act 1983, was transferred to Northwick Park Hospital after becoming unwell and developing myocarditis associated with Clozapine medication. She deteriorated in the Acute Assessment Unit, was found unresponsive, resuscitated and transferred to Critical Care, where she died; concerns included staff competence and training in use of the NEWS system, communication, responses to monitoring alarms and consideration of alternative monitoring.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between staff at all levels
Wider context from the report “The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score system and communication between all levels of staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff competence and training in use of the NEW Score system
Wider context from the report “The level of competence and training of staff working in the Acute Assessment Unit with regard to the use of NEW Score system and communication between all levels of staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternate forms of monitoring during continuous alarms
Wider context from the report “No consideration was given , when the alarms were continuously sounding , for alternate forms of monitoring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North Middlesex University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of monitoring equipment alarms to trigger senior staff attendance
Wider context from the report “That when the monitoring equipment alarmed this did not result in senior staff attending .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations