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recurance

Andres Roberts

23 Sept 2020 · Coroner Colin Phillips · Swansea and Neath Port Talbot

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. delayed thrombolysis leading to poor recovery and death

    “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. The deceased was thrombolysed with 4.5 hours of stroke onset, however, based on research and clinical data if the patient was to arrive in A&E sooner then he would have received the above mentioned treatment earlier which may have affected the outcome. Unfortunately, the stroke consultant was unable to comment on the exact”

Linked reports

Raised again laterAngela Darlow5 Feb 2026 · 5 years 4 months later
Identical hazardConfidence 0.90 · high

This report

“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 report

“Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend.”
Original on judiciary.uk ↗
Full chain: Delayed access to acute stroke treatment

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error