Jasbir Pahal
8 Dec 2023 · Coroner Oliver Longstaff · West Yorkshire (Eastern)
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of thrombectomy service at CRH
“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.”
2. delayed thrombectomy beyond optimal window
“Thrombectomy is a time-sensitive procedure, requiring to be performed within six hours of the onset of stroke symptoms to have its best chance of being successful, although it can be performed outside of that timeframe if investigative imaging suggests it may still be effective.”
3. inadequate out-of-hours thrombectomy provision
“Anyone whose nearest hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service.”
4. geographic inequity in stroke treatment access
“It is undesirable that patients such as [the deceased] should be subject to the vagaries of local arrangements when they are in urgent need of potentially life-saving treatment, and that they should be denied access to such treatment simply by reason of their home address.”
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
“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.”
Identical hazardConfidence 0.90 · high
Earlier report
“There is no thrombectomy service available 24/7 for RCHT patients.”
This 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
“Anyone whose nearest hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service.”
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.”
Closely relatedConfidence 0.90 · high
This 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.”
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”
Responses
No published response was found on judiciary.uk.