Inconsistent access to thrombectomy services
NHS England received 7 coroners' reports about this hazard between 6 Mar 2020 and 17 Jun 2025.
They came from 6 different coroners in 6 coroner areas. A similar concern was raised again 6 times after the first warning.
A published response was found for 5 of the 6 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“PHE will ensure that stroke is included in the health risks of cocaine use on FRANK”
Web search (Tavily): No evidence found either way
How to reduce your risk of a stroke ↗“NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years.”
Stated timescale: 5-year period
Web search (Tavily): No evidence found either way
1868-Thrombectomy-Service-Specification.pdf ↗- 2 years 9 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 1 year later
Raised again · 2nd time
Sarah Read↗
17 Nov 2023 · Christopher Long · Lancashire and Blackburn with Darwen
Closely relatedConfidence 0.90 · higha different coroner“Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
Original on judiciary.uk ↗ Repeated from the earlier report:ThrombectomyServicepatients
NHS England responded, stating 1 specific action.Response (PDF) ↗
“The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”
Web search (Tavily): No evidence found either way
NHS England Publishes Board Papers Amid Major Structural ... ↗ - 1 month laterIdentical hazardConfidence 0.90 · higha different coroner
“Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to [the deceased]'s home address, does not offer a thrombectomy service, whether in or out of hours.”
Original on judiciary.uk ↗ Repeated from the earlier report:thrombectomyservice
No published response from NHS England was found for this report.
- 1 year 3 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.”
Original on judiciary.uk ↗ Repeated from the earlier report:thrombectomybetweenhours
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 3 months later
Raised again · 5th time
Michelle Mason↗
2 Jun 2025 · Christopher Long · Lancashire and Blackburn with Darwen
Identical hazardConfidence 0.90 · higha different coroner“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Original on judiciary.uk ↗ Repeated from the earlier report:servicethrombectomy
NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 0 months laterIdentical hazardConfidence 0.95 · higha different coroner
“there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West.”
Original on judiciary.uk ↗ Repeated from the earlier report:availabilitythrombectomy
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2022Anthony Reedman2 years 9 months after 2020-0061 · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight insufficient access to thrombectomy services leading to preventable deaths. The earlier report notes variable availability by geography and timing, while the later report specifies a lack of 24/7 provision for a specific trust.
2020-0061 · 6 Mar 2020
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ Anthony Reedman · 22 Nov 2022
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ 2022 → 2023Sarah Read1 year after Anthony Reedman · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the absence of out‑of‑hours thrombectomy services for stroke patients, leading to delayed or denied lifesaving treatment.
Anthony Reedman · 22 Nov 2022
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ Sarah Read · 17 Nov 2023
“Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
Original on judiciary.uk ↗ 2020 → 2023Sarah Read3 years 8 months after 2020-0061 · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with timely access to thrombectomy services for stroke patients. The earlier report notes geographic and timing variability, while the later report points to a lack of after‑5 pm provision and regional coordination in Lancashire.
2020-0061 · 6 Mar 2020
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ Sarah Read · 17 Nov 2023
“(1) Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years.”
2022 → 2023Jasbir Pahal1 year 1 month after Anthony Reedman · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a 24/7 thrombectomy service for stroke patients at a specific hospital. They describe the same gap in service provision despite different locations.
Anthony Reedman · 22 Nov 2022
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ Jasbir Pahal · 8 Dec 2023
“Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to [the deceased]'s home address, does not offer a thrombectomy service, whether in or out of hours.”
Original on judiciary.uk ↗ 2020 → 2023Jasbir Pahal3 years 9 months after 2020-0061 · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that timely thrombectomy treatment is not reliably available because of geographic limitations and restricted service hours. This creates a risk of preventable deaths from stroke.
2020-0061 · 6 Mar 2020
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ Jasbir Pahal · 8 Dec 2023
“Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to [the deceased]'s home address, does not offer a thrombectomy service, whether in or out of hours.”
Original on judiciary.uk ↗ 2023 → 2025Barry Myers1 year 3 months after Jasbir Pahal · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that patients cannot receive thrombectomy services outside regular daytime hours due to limited provision or funding. The earlier report cites restricted operating hours; the later report cites insufficient funding for overnight service.
Jasbir Pahal · 8 Dec 2023
“Anyone whose nearest hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service.”
Original on judiciary.uk ↗ Barry Myers · 12 Mar 2025
“The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.”
Original on judiciary.uk ↗ 2022 → 2025Barry Myers2 years 4 months after Anthony Reedman · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that thrombectomy services are not reliably available outside normal working hours, leading to missed treatment opportunities. The earlier report cites a complete lack of 24/7 provision in Cornwall, while the later report points to insufficient funding limiting service to 4 pm–8 am at a Sussex trust.
Anthony Reedman · 22 Nov 2022
“Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedures did not receive this procedure because it is not available 24/7 in Cornwall”
Original on judiciary.uk ↗ Barry Myers · 12 Mar 2025
“The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.”
Original on judiciary.uk ↗ 2022 → 2025Michelle Mason2 years 6 months after Anthony Reedman · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a 24/7 thrombectomy service despite it being specified or considered lifesaving. The core concern is the lack of round‑the‑clock access to thrombectomy for stroke patients.
Anthony Reedman · 22 Nov 2022
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ Michelle Mason · 2 Jun 2025
“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Original on judiciary.uk ↗ 2023 → 2025Michelle Mason1 year 6 months after Sarah Read · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of a reliable out‑of‑hours thrombectomy service for stroke patients in Lancashire. They note that while national or regional specifications call for 24/7 availability, no effective coordination or plan exists to deliver the treatment after regular hours.
Sarah Read · 17 Nov 2023
“Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
Original on judiciary.uk ↗ Michelle Mason · 2 Jun 2025
“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”
2023 → 2025Michelle Mason1 year 6 months after Jasbir Pahal · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient access to thrombectomy services due to limited availability hours.
Jasbir Pahal · 8 Dec 2023
“Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to [the deceased]'s home address, does not offer a thrombectomy service, whether in or out of hours.”
Original on judiciary.uk ↗ Michelle Mason · 2 Jun 2025
“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Original on judiciary.uk ↗ 2020 → 2025Michelle Mason5 years 3 months after 2020-0061 · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient access to thrombectomy services leading to preventable deaths. The earlier report notes geographic and timing variability, while the later report specifies a missing 24/7 service in Lancashire.
2020-0061 · 6 Mar 2020
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ Michelle Mason · 2 Jun 2025
“NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service”
Original on judiciary.uk ↗ 2020 → 2025Greta Lewis5 years 3 months after 2020-0061 · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight insufficient access to thrombectomy services leading to preventable deaths. The earlier report notes variable availability by geography and timing; the later report identifies a specific gap in the South West.
2020-0061 · 6 Mar 2020
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Original on judiciary.uk ↗ Greta Lewis · 17 Jun 2025
“there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West.”
Original on judiciary.uk ↗ 2023 → 2025Greta Lewis1 year 7 months after Sarah Read · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of thrombectomy service for stroke patients in a specific region.
Sarah Read · 17 Nov 2023
“Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire.”
Original on judiciary.uk ↗ Greta Lewis · 17 Jun 2025
“The evidence revealed that there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”
2022 → 2025Greta Lewis2 years 7 months after Anthony Reedman · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight the absence of a 24/7 thrombectomy service for stroke patients in their respective regions. The earlier report focuses on Cornwall, while the later report notes a broader gap across the South West.
Anthony Reedman · 22 Nov 2022
“There is no thrombectomy service available 24/7 for RCHT patients.”
Original on judiciary.uk ↗ Greta Lewis · 17 Jun 2025
“there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West”
Original on judiciary.uk ↗
Stated action
“PHE will ensure that stroke is included in the health risks of cocaine use on FRANK”
What happened next: No evidence found either way
The NHS England webpage on stroke causes and prevention does not mention cocaine use or any health risks associated with it.
“stroke I'm too young to think about stroke Around a quarter of all strokes happen to people under 65, who may feel fit and healthy. To learn more about risk of stroke, see Page 5. I'm older or have some health problems It is never too late to take steps to reduce your risk of a stroke, like being more active, eating healthily and treating your health problems. To find out more, see Page 9. I have”
No evidence found does not mean the action did not happen.
Stated action · timescale: 5-year period
“NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years.”
What happened next: No evidence found either way
The NHS England thrombectomy service specification outlines a five-year rollout plan starting in April 2017, but no source confirms that the promised national rollout via specialised neuroscience centres was completed or operational.
“1. Scope 1.1 Prescribed Specialised Service This service specification covers the provision of stroke thrombectomy services for adults in England that should be available within a limited number of centres that deliver integrated stroke services, rather than in a specialised neuroscience centre.”
“The provision of mechanical thrombectomy services in England .........................................”
“MT provision requires specialist infrastructure at”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action
“The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”
What happened next: No evidence found either way
The document does not mention any interim offer for Lancashire or a Medical Director for Specialised Commissioning working with three units in the North West.
“NHS England has published the board papers from its 27 March 2025 meeting: the first since the announcement that the organisation will be brought under the Department of Health and Social Care (DHSC).”
No evidence found does not mean the action did not happen.
No published response from NHS England was found for this report.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2022 | 0.73 | 0.22 | Identical · 0.90 | different |
| 2022 → 2023 | 0.78 | 0.23 | Closely related · 0.90 | different |
| 2020 → 2023 | 0.71 | 0.16 | Closely related · 0.90 | different |
| 2022 → 2023 | 0.79 | 0.29 | Identical · 0.90 | different |
| 2020 → 2023 | 0.70 | 0.20 | Identical · 0.90 | different |
| 2023 → 2025 | 0.76 | 0.13 | Closely related · 0.80 | different |
| 2022 → 2025 | 0.75 | 0.14 | Closely related · 0.80 | different |
| 2022 → 2025 | 0.82 | 0.44 | Identical · 0.90 | different |
| 2023 → 2025 | 0.85 | 0.28 | Identical · 0.90 | same |
| 2023 → 2025 | 0.77 | 0.31 | Closely related · 0.90 | different |
| 2020 → 2025 | 0.73 | 0.21 | Closely related · 0.90 | different |
| 2020 → 2025 | 0.70 | 0.17 | Identical · 0.95 | different |
| 2023 → 2025 | 0.76 | 0.18 | Closely related · 0.90 | different |
| 2022 → 2025 | 0.79 | 0.26 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.