On 21 st December 2022 I commenced an investigation into the death of Jasbir Kaur Pahal, aged 42 (03/09/1978). The investigation concluded at the end of the Inquest on 25th October 2023. The conclusion of the Inquest was that Jasbir's death was caused by an ischaemic stroke. An extensive narrative conclusion is summarised in Section 4 below.

At 0205 hrs on Sunday 13th November 2022, Jasbir Pahal was observed to have fallen out of bed and to be exhibiting signs indicative of having had a stroke. She was taken by ambulance to Calderdale Royal Hospital, arriving in the Emergency Department at 0407 hrs, her arrival being delayed by the acuity of demand upon the ambulance service and adverse weather conditions on the road. A CT scan showed an acute left middle cerebral artery infarction. Jasbir did not receive thrombolysis ("clot busting medication") because more than four and a half hours had passed since she had last been seen well the previous evenino, and she was hence outside the window of opportunity within which that treatment could have been offered to her before the risks of doing so would have outweighed its potential benefits. Clinicians at Calderdale did not offer Jasbir a thrombectomy procedure (mechanical removal of a clot), because she would have had to be transferred to Leeds General Infirmary to undergo this procedure, and the protocol in place between Calderdale and Leeds authorised such transfers to take place only between 0800 hrs and 1500 hrs on Mondays to Fridays. Calderdale had no arrangements in place with any other hospital for the provision of thrombectomy services outside these hours. Following a telephone call from an Emergency Department Registrar at Calderdale, the Royal Stoke University Hospital ("Stoke"), who operate a 24 hour thrombectomy service, agreed to accept Jasbir as a patient, despite not having an agreement in place for the provision of out of hours thrombectomy services to Calderdale patients. At about the same time, the on-call stroke consultant at Leeds had spoken to one of the Leeds interventional radiologists who agreed to accept Jasbir as a patient and to come into Leeds to perform a thrombectomy, although there was normally no thrombectomy service at Leeds in the early hours of Sunday morning, and there was no arrangement between Calderdale and Leeds for an out of hours thrombectomy service for Calderdale patients. An ambulance crew began to take Jasbir from Calderdale to Stoke but were instructed to turn round and bring her to Leeds, where a CT head scan showed extensive infarct involving most of the left side of her brain, such that mechanical thrombectomy would 14th not improve her functional outcome. A further CT head on November confirmed a suspected diagnosis of malignant MCA (middle coronary artery) syndrome, necessitating an urgent decompressive hemicraniectomy following which she was transferred to the intensive care unit. Active treatment was withdrawn on 27th November and Jasbir was managed palliatively until her death on 30th November. CORONER'S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to Jasbir's home address, does not offer a thrombectomy service, whether in or out of hours. (2) 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) In common with similar arrangements applying to other district general hospital NHS Trusts in West Yorkshire, NHS England has commissioned the provision of a thrombectomy service to Calderdale and Huddersfield NHS Foundation Trust (CHFT) stroke patients by Leeds Teaching Hospitals NHS Trust (LTHT), whereby stroke patients admitted to Calderdale Royal Hospital and potentially requiring thrombectomy can be transferred for this purpose to Leeds General Infirmary (LGI). (4) No similar service has been commissioned for CHFT stroke patients from any other Trust. 8 (5) The existing arrangement between CHFT and L THT (and between other Trusts within the Regional Integrated Stroke Delivery Network and L THT) operates only between 0800 and 1500 hrs on weekdays (Monday to Friday), that is, for 35 out of 168 hours in a week (20.8%). 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. (6) That this level of service is inadequate is illustrated by the historical practice of thrombectomies being performed at LGI outside of the stated hours on an occasional ad hoc basis, dependent (among other factors) upon the availability and willingness of an interventional neuroradiologist to attend on a voluntary basis when not on call, to perform a potentially life-saving procedure. Among other reasons, it being considered inappropriate that clinicians should be exposed to the moral dilemma of agreeing or declining to perform such a life-saving procedure outside of their working or on-call hours, L THT has as from June 2023 stopped accepting such ad hoc referrals. (7) It is undesirable that patients such as Jasbir 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. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th January 2024. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ; Calderdale and Huddersfield NHS Foundation Trust; Leeds Teaching Hospitals NHS Trust; Yorkshire Ambulance Service NHS Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: 81h December 2023 9