Finding into death of Jessica Anne Katgert

41y · Female·Cardiomegaly

Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle and moderate aortic regurgitation. Autopsy revealed severe cardiac disease with myocardial fibrosis and a functionally bicuspid aortic valve from fusion and calcification. She was in custody for only four days; healthcare staff appropriately assessed her medical history and initiated continuity of care. The coroner found no causal connection between custody and her natural death. Minor policy gaps in incident response were identified (cell key access, CPR initiation) but would not have altered the outcome as she was already deceased when discovered.