Margaret Crooks
PFD Report
All Responded
Ref: 2025-0581
All 1 response received
· Deadline: 9 Jan 2026
Coroner's Concerns (AI summary)
Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
View full coroner's concerns
The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand. During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical. In Mrs Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs Crooks was at Stepping Hill appears to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome.
Responses
Action Planned
NHS Greater Manchester is reviewing and amending the Standard Operating Procedure (SOP) between the Comprehensive Stroke Centre (CSC) and other Greater Manchester stroke centres to clarify specialist stroke advice. The amended wording will be formally approved by the end of February 2026. (AI summary)
NHS Greater Manchester is reviewing and amending the Standard Operating Procedure (SOP) between the Comprehensive Stroke Centre (CSC) and other Greater Manchester stroke centres to clarify specialist stroke advice. The amended wording will be formally approved by the end of February 2026. (AI summary)
View full response
Dear Alison
Re: Regulation 28 Report to Prevent Future Deaths – Margaret Crooks
Thank you for your Regulation 28 Report dated 14 November 2025 regarding the sad death of Margaret Crooks. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Margaret’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on the 10 November 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand. During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical. In Mrs. Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs. Crooks was at Stepping Hill appears Private & Confidential Alison Mutch Senior Coroner for the area of Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs. Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome.
Greater Manchester benefits from the Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network (GM NISDN). Launched in October 2021, the Network is a partnership of NHS providers and commissioners of stroke and neurorehabilitation care in the Greater Manchester region, including Eastern Cheshire. The network supports the whole care pathway for stroke whilst focusing on community care for neurorehabilitation patients. The network supports the development of high quality and equitable stroke and community neurorehabilitation services in Greater Manchester, to achieve the best outcomes and experience for patients.
Hyper acute care within Greater Manchester is commissioned as a hub and spoke model - the hub being the Comprehensive Stroke Centre (CSC) based at Salford Royal operating 24/7 and spokes being Acute Stroke Centres (ASC) at Fairfield General and Stepping Hill Hospitals who both operate 6.45 am – 10.45 pm only. The CSC service specification outlines how patients can access care and support, with the CSC operating out of hours care when the ASCs are closed.
On receipt of your Regulation 28 Report, the Network has:
• Reviewed the currently approved Comprehensive Stroke Centre (CSC) service specification (attached with this letter) that Salford Royal Hospital (part of Northern Care Alliance NHS Foundation Trust) is commissioned to provide for the region. The specification has been in place since 2015 when the region re-organised its hyper acute stroke care pathway.
• Reviewed the current Standard Operating Procedure (SOP) between CSCs and the other Greater Manchester stroke centres that details the protocol to be followed in terms of provision of hyper acute advice out of hours.
On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.
I trust this information is useful. Please contact me should you require further information.
Best wishes
MBcHB MRCGP DRCOG DFFP PGCGPE Chief Medical Officer Caldicott Guardian NHS Greater Manchester
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Encs:
GM NISDN Comprehensive Stroke Centre (CSC) service specification
GM inpatient service specs incl TIA MOD1 V
Re: Regulation 28 Report to Prevent Future Deaths – Margaret Crooks
Thank you for your Regulation 28 Report dated 14 November 2025 regarding the sad death of Margaret Crooks. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Margaret’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on the 10 November 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand. During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical. In Mrs. Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs. Crooks was at Stepping Hill appears Private & Confidential Alison Mutch Senior Coroner for the area of Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs. Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome.
Greater Manchester benefits from the Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network (GM NISDN). Launched in October 2021, the Network is a partnership of NHS providers and commissioners of stroke and neurorehabilitation care in the Greater Manchester region, including Eastern Cheshire. The network supports the whole care pathway for stroke whilst focusing on community care for neurorehabilitation patients. The network supports the development of high quality and equitable stroke and community neurorehabilitation services in Greater Manchester, to achieve the best outcomes and experience for patients.
Hyper acute care within Greater Manchester is commissioned as a hub and spoke model - the hub being the Comprehensive Stroke Centre (CSC) based at Salford Royal operating 24/7 and spokes being Acute Stroke Centres (ASC) at Fairfield General and Stepping Hill Hospitals who both operate 6.45 am – 10.45 pm only. The CSC service specification outlines how patients can access care and support, with the CSC operating out of hours care when the ASCs are closed.
On receipt of your Regulation 28 Report, the Network has:
• Reviewed the currently approved Comprehensive Stroke Centre (CSC) service specification (attached with this letter) that Salford Royal Hospital (part of Northern Care Alliance NHS Foundation Trust) is commissioned to provide for the region. The specification has been in place since 2015 when the region re-organised its hyper acute stroke care pathway.
• Reviewed the current Standard Operating Procedure (SOP) between CSCs and the other Greater Manchester stroke centres that details the protocol to be followed in terms of provision of hyper acute advice out of hours.
On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.
I trust this information is useful. Please contact me should you require further information.
Best wishes
MBcHB MRCGP DRCOG DFFP PGCGPE Chief Medical Officer Caldicott Guardian NHS Greater Manchester
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Encs:
GM NISDN Comprehensive Stroke Centre (CSC) service specification
GM inpatient service specs incl TIA MOD1 V
Sent To
- Greater Manchester Integrated Care
Response Status
Linked responses
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56-Day Deadline
9 Jan 2026
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
I commenced an investigation into the death of Margaret Crooks. The investigation concluded at the end of the inquest on 10th November 2025. The conclusion of the inquest was narrative: Died of the complications of medical treatment. The medical cause of death was 1a) Intracerebral haemorrhage 1b) Intravenous thrombolysis.
Circumstances of the Death
Margaret Crooks attended Stepping Hill Hospital and was diagnosed as having a stroke. She was given intravenous thrombolysis as she met the criteria to be offered it. She subsequently developed complications from the thrombolysis. A CT scan reported at 00:28 confirmed a large bleed caused by the thrombolysis medication. Advice was sought from Salford Royal Hospital as the out of hours support is to be provided by that trust after11:30pm in accordance with the Greater Manchester protocol. The doctors at Stepping Hill Hospital were not advised to give medication to try and prevent further bleeding. They should have been. She was transferred to Salford Royal Hospital where the treatment was given. However, she continued to deteriorate and died at Salford Royal Hospital on 20th February 2025.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.