Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
2020-0061 · 6 Mar 2020 · Richard Brittain, Inner North London
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
What was promised
Stated action 1 · response to 2020-0061 (6 Mar 2020) · stated timescale: none stated
“PHE will ensure that stroke is included in the health risks of cocaine use on FRANK”
judiciary.uk/…/2020-0061-Response-from-Public-Health-England_.p…
Stated action 2 · response to 2020-0061 (6 Mar 2020) · stated 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.”
judiciary.uk/…/2020-0061-Response-from-NHS-England-and-NHS-Impr…
Stated action 3 · response to Sarah Read (17 Nov 2023) · stated timescale: none stated
“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 recurred
- 22 Nov 2022 · Anthony Reedman · Guy Davies · Identical hazard · confidence 0.90 (high)
- 17 Nov 2023 · Sarah Read · Christopher Long · Closely related · confidence 0.90 (high)
- 8 Dec 2023 · Jasbir Pahal · Oliver Longstaff · Identical hazard · confidence 0.90 (high)
- 12 Mar 2025 · Barry Myers · Lisa Milner · Closely related · confidence 0.80 (moderate)
- 2 Jun 2025 · Michelle Mason · Christopher Long · Identical hazard · confidence 0.90 (high)
- 17 Jun 2025 · Greta Lewis · Philip Spinney · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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.”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“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”
How to reduce your risk of a stroke · stroke.org.uk/how_to_reduce_your_risk_of_stroke_guide.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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.”
1868-Thrombectomy-Service-Specification.pdf · england.nhs.uk/…/1868-Thrombectomy-Service-Specification.pdf
“The provision of mechanical thrombectomy services in England .........................................”
Mechanical Thrombectomy delivery in England · gettingitrightfirsttime.co.uk/…/Mechanical-Thrombectomy-deliver…
“MT provision requires specialist infrastructure at”
Access to mechanical thrombectomy for stroke in the UK · svn.bmj.com/content/early/2026/03/24/svn-2025-004559
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“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).”
NHS England Publishes Board Papers Amid Major Structural ... · hssnews.com/…/nhs-england-publishes-board-papers-amid-major-str…
No evidence found does not mean the action did not happen.