Recurring concern

Unreliable cardiology pathways for specialist review

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First reported 23 Oct 2025•Latest report 6 Mar 2026

Definition

What this concern includes

Includes failures in cardiology pathways for selecting, escalating, routing or triggering specialist review, including unclear referral routes for complex or urgent cases and absent or inadequate guidance linking clinically significant cardiology data to specialist review.

Not included

Excludes generic referral, communication or pathway failures without an explicit cardiology specialist-review context.
Excludes clinical treatment, investigation or monitoring failures after appropriate cardiology review has been obtained.
Excludes non-cardiology specialist pathways and generic healthcare referral processes.
Excludes failures limited to cardiology service capacity or consultant availability where the pathway for directing or triggering review is otherwise reliable.

Reports: 3
Individual concerns: 4
Date range: 2025–2026
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cardiff & Vale University LHB1

NHS England1

NHS North Central London Integrated Care Board1

NHS West and North London Integrated Care Board1

the Shrewsbury and Telford Hospital NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

6 Mar2026
Gwent
Concerns raised1
1. Lack of guidance on when pacemaker data should trigger cardiology review
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Implement revised device escalation and referral criteria, including a mandatory referral trigger for loss of a twofold safety margin.
  Stated by Cardiff & Vale University LHBStated completed
2. Action
  Share the device escalation SOP with all physiologists.
  Stated by Cardiff & Vale University LHBStated completed
3. Action
  Present the device escalation SOP at the departmental Quality and Safety meeting.
  Stated by Cardiff & Vale University LHBStated planned
1. Action
  Circulate guidance on when and how physiologists should escalate patients to a cardiologist.
  Stated by Cardiff & Vale University LHBStated completed
AI-generated summary

Alan Bevis TOMLINSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alan Bevis TOMLINSON attended hospital on 16 April 2024 with illness, significant weight loss, anaemia and swelling around his pacemaker site, but was advised to return home because no cardiac bed was available. He died at home on 18 April 2024 from the effects of untreated infective endocarditis, likely associated with a longstanding infection at the pacemaker implant site. Concerns included missed referral to cardiology despite increasing pacemaker thresholds and visible illness, and failures to identify infective endocarditis, gather and document clinical information, and communicate findings effectively.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on when pacemaker data should trigger cardiology review
Wider context from the report
“Evidence from the Chief Physiologist identified wider concerns within the service, including: 1. Lack of guidance on when pacemaker data should trigger cardiology review; 2. Limited physiologist knowledge of infective endocarditis; 3. Inconsistent gathering of clinical information and implant site checks during clinic visits; 4. How clinical findings were documented and communicated, particularly to the Cardiology team. ”
Source location
Alan Bevis TOMLINSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement revised device escalation and referral criteria, including a mandatory referral trigger for loss of a twofold safety margin.

Verbatim wording from the response
“Actions The Health Board takes these findings extremely seriously. In response, the following actions have already been implemented:”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 10 March 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the device escalation SOP with all physiologists.

Verbatim wording from the response
“• A mandatory referral trigger is now in place if a device has lost a twofold safety margin. This has been clearly documented in the “Managing the Unwell Patient Standard Operating Procedure” (attached) which is stored on the departmental SharePoint.”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 10 March 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Present the device escalation SOP at the departmental Quality and Safety meeting.

Verbatim wording from the response
“• A mandatory referral trigger is now in place if a device has lost a twofold safety margin. This has been clearly documented in the “Managing the Unwell Patient Standard Operating Procedure” (attached) which is stored on the departmental SharePoint.”

Source location
Response from Cardiff and Vale University Health Board
Page 1 · response
Published 10 March 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate guidance on when and how physiologists should escalate patients to a cardiologist.

Verbatim wording from the response
“• Training sessions have been arranged for delivery covering: ○ Recognition of infective endocarditis, including atypical presentations, will be delivered by a Consultant Cardiologist. ○ Recognising the generally unwell patient and Red Flags which will be delivered by the Nursing Practice Educators. ○ When and how to escalate to a cardiologist has been circulated via e-mail and will be delivered on the 13th of May Quality and Safety afternoon.”

Source location
Response from Cardiff and Vale University Health Board
Page 2 · response
Published 10 March 2026
Open published response
10 Nov2025
Inner North London
Concerns raised2
1. Lack of overarching guidance directing GPs to the appropriate cardiology pathway for complex cases
2. Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Update the suspected heart failure pathway to clarify urgent referral routes and align them with two-week and two-to-six-week clinic provision.
  Stated by North Central London ICBStated completed
2. Action
  Promote the updated suspected heart failure assessment and diagnosis pathway through primary care bulletins, the website and a GP webinar.
  Stated by North Central London ICBStated planned
AI-generated summary

Costas CHRYSOSTOMOU · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Costas Chrysostomou died in hospital on 14 December 2024 after developing cardiac failure and acute renal failure linked to pacemaker-mediated cardiomyopathy, described as a rare but known complication. The report raised concerns about ambiguity in the use of “urgent” referrals, differing understandings of cardiology pathways between GPs and hospital consultants, and the need for clearer guidance for complex cases.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of overarching guidance directing GPs to the appropriate cardiology pathway for complex cases
Wider context from the report
“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. ”
Source location
Costas CHRYSOSTOMOU · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways
Wider context from the report
“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. ”
Source location
Costas CHRYSOSTOMOU · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the suspected heart failure pathway to clarify urgent referral routes and align them with two-week and two-to-six-week clinic provision.

Verbatim wording from the response
“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.”

Source location
Response from North Central London Integrated Care Board
Page 2 · response
Published 7 April 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Promote the updated suspected heart failure assessment and diagnosis pathway through primary care bulletins, the website and a GP webinar.

Verbatim wording from the response
“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.”

Source location
Response from North Central London Integrated Care Board
Page 2 · response
Published 7 April 2026
Open published response
23 Oct2025
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to obtain cardiology review of discharge appropriateness
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
  Stated by NHS EnglandOutside remit
1. Position
  Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Lynn SILCOCK · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to obtain cardiology review of discharge appropriateness
Wider context from the report
“(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate. ”
Source location
Lynn SILCOCK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.

Verbatim wording from the response
“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location
Response from NHS England
Page 1 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.

Verbatim wording from the response
“The concerns raised in your Report will be dealt with by SATH, to whom your Report has also been addressed, and there is no action for NHS England to take in regard to this matter as the issues fall outside of NHS England’s role and remit as a commissioner of certain healthcare services. However, the following information may be useful to the Coroner as background.”

Source location
Response from NHS England
Page 1 · response
Published 19 December 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of guidance on when pacemaker data should trigger cardiology review

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised2

Lack of overarching guidance directing GPs to the appropriate cardiology pathway for complex cases

Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to obtain cardiology review of discharge appropriateness

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 4

Actions described in response 2

Respondent positions 2