Kerry Singh

25 th June 2026

ACTION SHOULD BE TAKEN: In my opinion, unless action is taken to address the above concerns (as detailed in paragraph 9 below) then there is a significant risk of future deaths and I believe you have the power to take such action.

INVESTIGATION AND INQUEST: On the 16 th July 2025, I commenced an investigation into the death of Kerry Teresa Singh, aged 37 years. The inquest was heard on the 22 nd and 23 rd June 2026. MY FINDINGS AS RECORDED ON THE RECORD OF INQUEST: The medical cause of death: Ia Bleeding and hypovolaemic shock IbTear of superior vena cava Ic Removal of failing pacemaker II Complete heart block associated with atrioventricular nodal re-entrant tachycardia How, when and where Kerry Singh came by her death: Kerry Singh was found to be suffering atrioventricular nodal re-entrant tachycardia in 2014. She was treated at the William Harvey Hospital in Kent where she underwent two unsuccessful ablation procedures, the second of which was complicated by damage to the atrioventricular node connection and consequential complete heart block. As a result, a dual chamber pacemaker was inserted in 2016. There was chronic noise in the pacemaker leads which raised a risk of the Deceased suffering sudden blackout and, by 2019, it was recognised that the leads would need to be replaced. However, when the pacemaker generator was replaced in 2021, due to its early depletion, a decision was made not to replace the leads at the same time. Subsequently, the Deceased continued to suffer episodes of tachycardia and she periodically attended the hospital’s emergency department, via ambulance, with symptoms including dizzy episodes and chest pain; by 2023, her symptoms were  worsening and by late 2024, her daily functioning was significantly adversely affected. On the 30th December 2024, a 24-hour tape test reported evidence of intermittent failure of the pacing system which increased the risk of sudden blackout, but the report was not viewed by the responsible clinician until March 2025. A multidisciplinary team meeting then took place on the 3rd April 2025 at which it was decided that the Deceased should be referred to a tertiary centre for pacemaker lead removal and replacement, but the responsible clinician did not make the referral. On the 7th July 2025, the Deceased suffered a syncopal blackout because of complete intermittent failure of the pacing system. She was taken by ambulance to the hospital from where she was transferred, on the 11th July 2025, to St. Bartholomew’s Hospital, London. On the 14th July 2025, she there underwent urgent lead extraction in the course of which the tip of the ventricular lead released before the sheath was advanced to cover it, causing the sheath to straighten and flick on to the lateral superior vena cava and to tear it. This is a recognised complication of the procedure. Further, post mortem evidence revealed inflammation in the area of the tear and this may have made it more vulnerable to damage. Following the extraction, the Deceased suffered a cardiac arrest as a result of bleeding from the tear. Resuscitation was commenced immediately, and an occlusion balloon was placed, but surgical repair was judged not to be feasible. A pericardial effusion developed and was drained but, despite all efforts, cardiac output could not be restored. Consequently, resuscitation was stopped and the Deceased’s death was confirmed at 13.10 hours on the 14th July 2025. There was delay in referring the Deceased for the extraction procedure but it is not possible to know whether her death would have been avoided if the procedure had been performed at an earlier date or on an elective basis. Conclusion as to the death: Died as a result of a recognised complication of a necessary procedure which was performed to remove and replace a failing medical device.