2020-0061
6 Mar 2020 · Coroner Richard Brittain · Inner North London
A similar concern from this report was raised again 5 times later. See the linked reports.
The coroner's concerns
1. stroke arising from cocaine use
“The MATTERS OF CONCERN following the inquest were as follows:”
2. thrombectomy service access variability
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing. I am concerned that this variation will mean that future deaths will occur in similar circumstances, unless access to thrombectomy services is improved.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Later report
“There is no thrombectomy service available 24/7 for RCHT patients.”
Closely relatedConfidence 0.90 · high
This report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Later report
“(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.”
Identical hazardConfidence 0.90 · high
This report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Later report
“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.”
Closely relatedConfidence 0.90 · high
This report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Later report
“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”
Identical hazardConfidence 0.95 · high
This report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
Later report
“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.”
Responses
2020-0061-Response-from-NHS-England-and-NHS-Improvement.pdf ↗· NHS England
Stated action · 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.”
2020-0061-Response-from-Public-Health-England_.pdf ↗· NHS England
Stated action
“PHE will ensure that stroke is included in the health risks of cocaine use on FRANK”