North Central London Integrated Care Board
Integrated Care Board
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)
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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.