Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed access to acute stroke treatment
The earlier warning
Andres Roberts · 23 Sept 2020 · Colin Phillips, Swansea and Neath Port Talbot
“In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival.”
judiciary.uk/prevention-of-future-death-reports/andres-roberts
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 5 Feb 2026 · Angela Darlow · Kate Robertson · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Andres Roberts · 23 Sept 2020
“In an acute stroke 'time is brain' which means that the sooner thrombolysis (clot busting drug) is administered the better are the chances of recovery and subsequent survival.”
Later · Angela Darlow · 5 Feb 2026
“Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend.”
What happened next
No web check of the stated actions has been published for this chain.