Anthony Reedman
22 Nov 2022 · Coroner Guy Davies · Cornwall and Isles of Scilly
This report repeats 1 earlier warning, and was raised again 5 times later. See the linked reports.
The coroner's concerns
1. lack of 24/7 thrombectomy service
“There is no thrombectomy service available 24/7 for RCHT patients”
2. no service level agreement for treatment of patients from Cornwall
“The nearest 24/7 thrombectomy service is at NHS North Bristol”
3. postcode lottery for thrombectomy access
“75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedures did not receive this procedure because it is not available 24/7 in Cornwall”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing.”
This report
“There is no thrombectomy service available 24/7 for RCHT patients.”
Closely relatedConfidence 0.90 · high
This report
“There is no thrombectomy service available 24/7 for RCHT patients.”
Later report
“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
“There is no thrombectomy service available 24/7 for RCHT patients.”
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 0.80 · moderate
This report
“Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedures did not receive this procedure because it is not available 24/7 in Cornwall”
Later report
“The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust.”
Identical hazardConfidence 0.90 · high
This report
“There is no thrombectomy service available 24/7 for RCHT patients.”
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”
Closely relatedConfidence 0.80 · moderate
This report
“There is no thrombectomy service available 24/7 for RCHT patients.”
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
2022-0375-Response-from-North-Bristol-NHS-Trust.pdf ↗· North Bristol NHS Trust