James Morris responded by outlining the background and history of cardiac services at St George’s, noting growing concerns about cultural issues that may have impacted service safety and quality. He explained that an independent mortality review was commissioned to address these concerns after two mortality alerts from NICOR. The review found shortcomings in 102 out of 202 deaths examined and identified problems contributing to the deaths of 67 heart surgery patients. Morris highlighted that since the mortality review, St George’s has improved its service quality and leadership, with mortality rates returning to normal levels and patient care outcomes improving. He acknowledged ongoing work by NHS England London region to enhance services at the cardiac unit and remove previous restrictions on practice. Morris emphasised that the referral of doctors was not due to the mortality review, which focused on safety issues rather than individual cases, citing legal constraints in commenting further. He concluded with a commitment to reviewing the coroner’s prevention of future deaths report and improving NHS investigations into serious patient safety incidents.