Thomas Morrell
17 Nov 2025 · Coroner Thomas Crookes · Newcastle and North Tyneside
The coroner's concerns
1. delayed recognition of heart failure in HOCM patient
“Following Mr [name redacted] 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 [name redacted] 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.”
2. failure to monitor cardiac deterioration between 2019 and 2024
“In 2019 an echocardiogram showed no changes to Mr [name redacted] 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.”