Gordon Renfrew
6 Jul 2023 · Coroner Elizabeth Didcock · Nottinghamshire
The coroner's concerns
1. limited communication and collaboration between stroke and neurosurgical teams
“There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust”
2. unclear understanding of NICE guidance on Decompression Craniectomy and referral criteria
“There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised”
3. limited joint case discussion and learning opportunities
“There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities - I note it was [REDACTED], (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that [the deceased] was reviewed by the Neurosurgical team on the early evening of the 7th June 2022”