PFD report

Thomas Colin Morrell · Prevention of Future Deaths report

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Issued 17 Nov 2025•Newcastle and North Tyneside

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised3

  1. Failure to undertake interval cardiac scans or echocardiograms to check for deterioration
    Part of recurring concern: Failure of echocardiography services to provide timely diagnostic assessment and follow-upPart of recurring concern: Failure to obtain clinically indicated repeat investigations
  2. Lack of a standard operating process for referring HOCM patients
    Part of recurring concern: Failure to reliably refer patients to required specialist services
  3. Failure to recognise the greater role of heart failure in deterioration
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Circulate guidance to relevant clinicians emphasising timely referral of appropriate patients to a transplant centre.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 November 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to undertake interval cardiac scans or echocardiograms to check for deterioration

Wider context from the report

“(2) In 2019 an echocardiogram showed no changes to Mr Morrell's heart but by 6 July 2021 a cardiac MRI scan showed focal hypertrophy and patchy scarring within the heart, with functional impairment in the mild to moderate range. On 16 October 2024 an echocardiogram showed severe biventricular failure. There were no scans / echocardiograms undertaken between those dates to check for deterioration. Had the deterioration been detected sooner, I was told in evidence that there may have been an earlier opportunity to intervene prior to deterioration into end stage heart failure, which may have improved the prospects of surgical intervention. ”

Is this part of a recurring concern?

Yes — Failure of echocardiography services to provide timely diagnostic assessment and follow-up; Failure to obtain clinically indicated repeat investigations.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a standard operating process for referring HOCM patients

Wider context from the report

“(1) Following Mr Morrell's emergency admission to Scarborough Hospital on 8 October 2024, heart failure (as opposed to abdominal issues) played a greater role in his deterioration than was initially recognised by the treating clinicians. Had this been recognised sooner, Mr Morrell could have been transferred to the Freeman Hospital more quickly. There was not a standard operating process in place for Hypertrophic Obstructive Cardiomyopathy (HOCM) patients covering when to refer patients in such circumstances. ”

Is this part of a recurring concern?

Yes — Failure to reliably refer patients to required specialist services.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to recognise the greater role of heart failure in deterioration

Wider context from the report

“(1) Following Mr Morrell's emergency admission to Scarborough Hospital on 8 October 2024, heart failure (as opposed to abdominal issues) played a greater role in his deterioration than was initially recognised by the treating clinicians. Had this been recognised sooner, Mr Morrell could have been transferred to the Freeman Hospital more quickly. There was not a standard operating process in place for Hypertrophic Obstructive Cardiomyopathy (HOCM) patients covering when to refer patients in such circumstances. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration.

Open source report

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

Circulate guidance to relevant clinicians emphasising timely referral of appropriate patients to a transplant centre.

Verbatim wording from the response

“We recognise that timely referral of appropriate patients to a transplant centre is an important step in management and have circulated this message to relevant clinicians. We have a well-established working relationship with the transplant centre in Newcastle including open communication on cases where we have concerns. For example, as part of this relationship, members of the Newcastle team presented to our cardiology governance meeting in autumn 2025.”

Source location

Response from York Scarborough Hospital
Page 1 · response
Published 18 November 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Urgent transplant referral was not warranted because treatable causes required optimisation first, and echocardiographic deterioration alone would not prompt referral.

    Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Urgent transplant referral was not warranted because treatable causes required optimisation first, and echocardiographic deterioration alone would not prompt referral.

Verbatim wording from the response

“Consideration of heart transplantation would require that the major treatable causes of heart failure are properly addressed prior. Heart function at echocardiography does not drive the need for heart transplantation, rather the ongoing symptom level once optimal therapy is in place would be the driver to consider heart transplant. As such echocardiography showing a deterioration in the function of the left ventricle on its own would not have prompted consideration of heart transplant. Mr Morrell was still undergoing optimisation of therapy, hence urgent referral for transplant assessment would not have materially advanced his management.”

Source location

Response from York Scarborough Hospital
Page 2 · response
Published 18 November 2025

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026