Costas Chrysostomou
PFD Report
All Responded
Ref: 2026-0177
All 1 response received
· Deadline: 2 Jun 2026
Coroner's Concerns (AI summary)
There is potential for confusion due to differing interpretations of the term 'urgent' in cardiology pathways, and a lack of clarity among third-party providers regarding available NHS ICB pathways. GPs may also be unclear about how to expedite referrals when new clinical information comes to light.
View full coroner's concerns
Based on the specific circumstances of this case, the evidence was such that the concerns raised in this report, were not likely to have made a difference in the outcome for Mr Chrysostomou. However, I consider that the evidence heard in the course of the inquest would, in different circumstance, result in the risk of future deaths.
1) Use of the term ‘urgent’ and understanding by third-party providers of the specific Pathways available Following implantation of the pacemaker, Mr Chrysostomou’s GP was charged with arranging a follow-up outpatient cardiology appointment and arranging for an echocardiogram (Echo). Both actions were undertaken by the GP.
A referral to the cardiology team at the Royal Free Hospital was made under what I was told was a ‘generic’ cardiology pathway as there was no expectation, at that time, for a more specific pathway to be used. The Echo was undertaken by a third-party (private) provider, contracted to provide services to the NHS. The Echo report was headed in large bold writing: ‘Suggest Urgent Cardiac Referral’. The bottom of the Echo report repeats that recommendation next to the heading ‘Onward Recommendations’.
The evidence I heard indicated that there are numerous potential cardiac/cardiology pathways available. The concern regarding the use of the term ‘urgent’ is that I heard evidence that this is open to interpretation; for example, there is in some Pathways an ‘Urgent 6 weeks’ type of referral and also an ‘Urgent (<2 weeks)’ type of referral. It is possible that the third-party provider(s) may not be aware of the differences and/or not sufficiently aware of the NHS ICB Pathways available, which is leading to confusion.
2) Understanding of Pathways
a. I heard evidence from cardiology consultants and a GP. It was clear that understanding of the operation of the Pathways differs considerably. One example was that some GPs consider that by custom and practice, if following a routine cardiology referral new clinical information comes to light requiring a patient’s referral to expedited or made ‘urgent’, this can be done by emailing the hospital team concerned and adding the information. However, the view of the hospital consultants is that this is not the case and that if an expedited or urgent referral becomes necessary then the referral process requires re-starting as a new and entirely separate referral. In my opinion, this confusion has the potential to create significant risk.
b. I also heard evidence more generally that with more complex specialisms/cases GPs could be assisted with overarching guidance that helps direct them to the most appropriate Pathway. At present, I was told, that the system relies on the GP being confident as to which Pathway is appropriate, which is understandably not always the case.
1) Use of the term ‘urgent’ and understanding by third-party providers of the specific Pathways available Following implantation of the pacemaker, Mr Chrysostomou’s GP was charged with arranging a follow-up outpatient cardiology appointment and arranging for an echocardiogram (Echo). Both actions were undertaken by the GP.
A referral to the cardiology team at the Royal Free Hospital was made under what I was told was a ‘generic’ cardiology pathway as there was no expectation, at that time, for a more specific pathway to be used. The Echo was undertaken by a third-party (private) provider, contracted to provide services to the NHS. The Echo report was headed in large bold writing: ‘Suggest Urgent Cardiac Referral’. The bottom of the Echo report repeats that recommendation next to the heading ‘Onward Recommendations’.
The evidence I heard indicated that there are numerous potential cardiac/cardiology pathways available. The concern regarding the use of the term ‘urgent’ is that I heard evidence that this is open to interpretation; for example, there is in some Pathways an ‘Urgent 6 weeks’ type of referral and also an ‘Urgent (<2 weeks)’ type of referral. It is possible that the third-party provider(s) may not be aware of the differences and/or not sufficiently aware of the NHS ICB Pathways available, which is leading to confusion.
2) Understanding of Pathways
a. I heard evidence from cardiology consultants and a GP. It was clear that understanding of the operation of the Pathways differs considerably. One example was that some GPs consider that by custom and practice, if following a routine cardiology referral new clinical information comes to light requiring a patient’s referral to expedited or made ‘urgent’, this can be done by emailing the hospital team concerned and adding the information. However, the view of the hospital consultants is that this is not the case and that if an expedited or urgent referral becomes necessary then the referral process requires re-starting as a new and entirely separate referral. In my opinion, this confusion has the potential to create significant risk.
b. I also heard evidence more generally that with more complex specialisms/cases GPs could be assisted with overarching guidance that helps direct them to the most appropriate Pathway. At present, I was told, that the system relies on the GP being confident as to which Pathway is appropriate, which is understandably not always the case.
Responses
Action Planned
Changes have been updated on the NCL Pathway for Suspected Heart Failure following contact with the Royal Free Heart Failure Lead. A working group is also being convened to review and update guidance, incorporating NICE guidelines, and an NHSE working group is developing a standard heart failure referral form. (AI summary)
Changes have been updated on the NCL Pathway for Suspected Heart Failure following contact with the Royal Free Heart Failure Lead. A working group is also being convened to review and update guidance, incorporating NICE guidelines, and an NHSE working group is developing a standard heart failure referral form. (AI summary)
View full response
Dear Coroner,
Re: Prevention of Future Deaths Report – Mr Costas Chrysostomou who died on 14th December 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th November 2025 concerning the death of Mr Costas Chrysostomou on 14th December
2024. Please accept North Central London (NCL) ICB’s sincere apologies for the delay in providing a response. The report was only brought to the attention of the Governance, Risk and Legal Services Team on 8 January 2026, further to your follow-up email, and no discourtesy to the Coroner’s Court was intended. Since becoming aware of the report, the Chief Nursing Officer’s Quality Team has been coordinating a response alongside senior support from the Deputy Medical Director, The Royal Free Hospital, primary care colleagues and commissioners to formulate the response. In addition to this we have been in the middle of an organisational restructure with merger of NCL and (North West London) NWL Integrated commissioning board.
In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Chrysostomou’s family and loved ones. NCL ICB is keen to assure the family and yourself that the areas raised as part of the evidence at the Inquest have been listened to and reflected upon. Your Report raised concerns around the use of the term ‘urgent’ and the understanding by third-party providers of the numerous cardiology pathways available. In addition, you heard evidence of different views between cardiologists and GPs of the pathway to expedite an urgent cardiac referral. You also heard more generally that with more complex specialisms/cases, GPs could be assisted with overarching guidance that helps direct
them to the most appropriate pathway. Although, in your Report you said that based on the specific circumstances of this case, the evidence was such that the concerns, were not likely to have made a difference in the outcome for Mr Chrysostomou you did consider that in different circumstances, these factors could result in a risk of future deaths. NCL ICB recognises the complexity of coronary vascular disease (CVD) pathways and significant pressures on cardiac services. In response to the specific areas of concern in your Report, we have taken the following action: An NCL pathway already exists for Suspected Heart Failure assessment and diagnosis on the NCL GP professional website. However, we recognise that there was a lack of clarity in referral pathways for urgent assessment in a patient with heart failure at the Royal Free whereby the GP referral was being sent in through the (Clinical Assessment service) CAS triage system- however the service was unable to guarantee that the urgent echo investigation would be reviewed within 2-6 weeks. We have since contacted the Royal Free Heart Failure Lead and in line with the service provision for urgent 2 week and 2-6 weeks clinic provision ,changes have now been updated on the NCL Pathway for Suspected Heart Failure Download: Heart Failure Diagnosis and Assessment in Adults - NCL ICB General Practice Website. Further guidance for management of heart failure to support clinicians with confirming a diagnosis and optimising management is also available on the NCL GP professional website
A working group is being convened with NCL specialist heart failure clinicians and NCL ICB Medicines Optimisation leads to review and update the guidance and ensure recommendations from the updated NICE guidelines NG106 on heart failure are incorporated to support clinical practice. There is also an NHSE working group developing a standard heart failure referral form for primary care to use when referring into secondary care, which will also support timely responses to Urgent referrals linked to the NT-pro BNP 2-week and 6-week pathways. NCL ICB will be promoting the updated Suspected Heart Failure assessment and diagnosis pathway via established NCL primary care channels including the NCL ICB General Practice Weekly bulletin, NCL General Practice Website and the NCL GP webinar on 26 March 2026. Finally, the joining of NCL ICB with Northwest London ICB to become West and North London (WNL) ICB from 1st April 2026, presents further valuable opportunities to ensure the learning from this work is shared and embedded across a broader geography and footprint.
Re: Prevention of Future Deaths Report – Mr Costas Chrysostomou who died on 14th December 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th November 2025 concerning the death of Mr Costas Chrysostomou on 14th December
2024. Please accept North Central London (NCL) ICB’s sincere apologies for the delay in providing a response. The report was only brought to the attention of the Governance, Risk and Legal Services Team on 8 January 2026, further to your follow-up email, and no discourtesy to the Coroner’s Court was intended. Since becoming aware of the report, the Chief Nursing Officer’s Quality Team has been coordinating a response alongside senior support from the Deputy Medical Director, The Royal Free Hospital, primary care colleagues and commissioners to formulate the response. In addition to this we have been in the middle of an organisational restructure with merger of NCL and (North West London) NWL Integrated commissioning board.
In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Chrysostomou’s family and loved ones. NCL ICB is keen to assure the family and yourself that the areas raised as part of the evidence at the Inquest have been listened to and reflected upon. Your Report raised concerns around the use of the term ‘urgent’ and the understanding by third-party providers of the numerous cardiology pathways available. In addition, you heard evidence of different views between cardiologists and GPs of the pathway to expedite an urgent cardiac referral. You also heard more generally that with more complex specialisms/cases, GPs could be assisted with overarching guidance that helps direct
them to the most appropriate pathway. Although, in your Report you said that based on the specific circumstances of this case, the evidence was such that the concerns, were not likely to have made a difference in the outcome for Mr Chrysostomou you did consider that in different circumstances, these factors could result in a risk of future deaths. NCL ICB recognises the complexity of coronary vascular disease (CVD) pathways and significant pressures on cardiac services. In response to the specific areas of concern in your Report, we have taken the following action: An NCL pathway already exists for Suspected Heart Failure assessment and diagnosis on the NCL GP professional website. However, we recognise that there was a lack of clarity in referral pathways for urgent assessment in a patient with heart failure at the Royal Free whereby the GP referral was being sent in through the (Clinical Assessment service) CAS triage system- however the service was unable to guarantee that the urgent echo investigation would be reviewed within 2-6 weeks. We have since contacted the Royal Free Heart Failure Lead and in line with the service provision for urgent 2 week and 2-6 weeks clinic provision ,changes have now been updated on the NCL Pathway for Suspected Heart Failure Download: Heart Failure Diagnosis and Assessment in Adults - NCL ICB General Practice Website. Further guidance for management of heart failure to support clinicians with confirming a diagnosis and optimising management is also available on the NCL GP professional website
A working group is being convened with NCL specialist heart failure clinicians and NCL ICB Medicines Optimisation leads to review and update the guidance and ensure recommendations from the updated NICE guidelines NG106 on heart failure are incorporated to support clinical practice. There is also an NHSE working group developing a standard heart failure referral form for primary care to use when referring into secondary care, which will also support timely responses to Urgent referrals linked to the NT-pro BNP 2-week and 6-week pathways. NCL ICB will be promoting the updated Suspected Heart Failure assessment and diagnosis pathway via established NCL primary care channels including the NCL ICB General Practice Weekly bulletin, NCL General Practice Website and the NCL GP webinar on 26 March 2026. Finally, the joining of NCL ICB with Northwest London ICB to become West and North London (WNL) ICB from 1st April 2026, presents further valuable opportunities to ensure the learning from this work is shared and embedded across a broader geography and footprint.
Sent To
Response Status
Linked responses
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56-Day Deadline
2 Jun 2026
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 18 December 2024, an investigation was commenced into the death of Mr Chrysostomou, aged 87 at the time of his death. The investigation concluded at the end of an inquest heard by me on 24 April 2025 (in St Pancras Coroner’s Court) and 23 October 2025 (in Poplar Coroner’s Court).
The inquest concluded with a short narrative conclusion of “Rare but known complication of a necessary medical treatment (pacemaker).” The medical cause of death was:
1a acute renal failure 1b congestive cardiac failure 1c pacemaker mediated cardiomyopathy II mixed aortic valve disease
The inquest concluded with a short narrative conclusion of “Rare but known complication of a necessary medical treatment (pacemaker).” The medical cause of death was:
1a acute renal failure 1b congestive cardiac failure 1c pacemaker mediated cardiomyopathy II mixed aortic valve disease
Circumstances of the Death
Costas Chrysostomou was diagnosed with 2:1 AV block and required a dual chamber pacemaker to be implanted to treat this. The implantation took place on 7 October 2024. Mr Chrysostomou attended ED twice (15 and 17 November) and saw a consultant cardiologist privately (26 November) and, while other known cardiac issues were followed up, there was no suggestion that he was in cardiac failure or required an emergency hospital admission on any of these occasions. On 6 December 2024, Mr Chrysostomou was admitted to the Royal Free Hospital and found to have cardiac failure and acute cardio renal syndrome as a consequence. Despite attempts at treatment, Mr Chrysostomou’s condition deteriorated and he died in the hospital on 14 December 2024. The heart failure and acute renal failure were a consequence of cardiomyopathy caused by the pacemaker, which is a rare but known complication.
Copies Sent To
Mr Chrysostomou’s GP practice; and
Royal Free Hospital, for information
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.