The investigation into the death of Neophytos Constantinou concluded at the end of the inqueston November 2014. The conclusion of the inquest was narrative

Mr Constantinou died, aged 73, at the Royal Free Hospital (RFH) on 22 March 2013 from the consequences 0f biliary stone disease. He had been investigated for suspected malignancy at the North Middlesex Hospital through late 2012 and into early 2013. Attempts t0 complete the necessary procedure (ERCP) had been unsuccessful and delayed He was referred for specialist investigation at RFH in late January 2013. Plans were made for a further ERCP to occur in early February 2013 Mr Constantinou required transportation from his home to RFH for this procedure: This had been acknowledged, as heard evidence that a call was received querying why transport was necessary also heard that Mr Constantinou confirmed the need for transport with his GP who, in turn, discussed this issue with staff from the North Middlesex Hospilal. Transport was confirmed as being booked through a telephone call to Mr Constantinou: However, on the of the procedure, the planned transport did not arrive and he missed the scheduled appointment heard evidence, only available on the of the inquest, that the hospital at which the procedure is to occur is usually responsible for arranging the transport it was postulated that, where a patient has not attended the hospital before, it is for the GP to arrange transportation This is despite the evidence presented t0 me from Mr Constantinou's family, who understood that North Middlesex Hospital had been central to arranging the transportation_ The RFH referral form for ERCP was adduced as evidence; it includes information regarding the need for transportation as a yeslno tick box day day

Following Mr Constantinous missed appointment he deterioraled and was admitted into the North Middlesex Hospital, from where he was ultimately transferred to RFH; However, despite investigation and treatment; he died: A post mortem demonstrated that he did not have malignancy but in fact biliary stone disease, which was the underlying cause of his death

In my opinion action should be taken to prevent future deaths and believe the addressees have the power t0 take such action; as regards clarifying the current position and taking steps to resolve any confusion, If this remains.