Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Greta Mary Ann Lewis who died on 12 July 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 June 2025 concerning the death of Greta Mary Ann Lewis on 12 July 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Greta’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Greta’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Greta’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raises the concern that there is a gap in the availability of time critical and potentially lifesaving emergency thrombectomy services in the South West, for patients who have suffered a severe stroke. You have recommended that consideration is given to the viability of a 24/7 service.

Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible commissioner for the Devon region, rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.

It is a priority for the NHS in England that all commissioned Comprehensive Stroke Centres (CSCs) provide a 24/7 thrombectomy service, regardless of a patient’s location. This has proved challenging in certain areas for a variety of reasons. In particular, the ability of services to expand and operate 24/7 is heavily reliant on recruiting the necessary specialist workforce with appropriate competencies.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

england.coronersr28@nhs.net 20 August 2025

Your Report does not detail the type of stroke suffered by Greta or the vessel which was affected, but it is relevant to note that not all ischaemic stroke patients are suitable for thrombectomy. The NHS Long Term Plan, published in January 2019, previously set an ambition for 10% of stroke patients to receive thrombectomy treatment (based on there being approximately 80,000 stroke admissions per year, and up to 8,000 of these patients potentially being eligible for thrombectomy). For those eligible patients with a large vessel occlusion to the anterior circulation, there is generally a 6 hour time interval from the onset of stroke symptoms to perform thrombectomy. Delivering treatment successfully depends on a number of factors, including timely diagnosis, conveyance to a CSC within the 6 hour timeframe, and the CSC’s operating hours and available workforce to perform the procedure.

National service development and improvements

Since January 2021, the national stroke programme has been engaging with the General Medical Council (GMC) and Royal College of Radiologists to support the development of a thrombectomy credentialing programme, including enabling non- INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and supported to perform thrombectomy and address the workforce gap. The GMC credential was published in June 2023. A substantial amount of revenue funding has since been made available to deliver the credentialing programme and the first cohort of trainees have already been enrolled and started the credential. The trainees are completing the credential alongside their full-time NHS employment in their main speciality, but it is hoped that some will be signed off within the next year. There have also been non-INRs, such as Interventional Radiologists, who have developed the skill of delivering mechanical thrombectomy and have joined the workforce in some units outside of this new route / credential.

I would also like to advise you that, alongside the national quality improvement programme, further work to ensure the ongoing service development of mechanical thrombectomy services has been supported by a programme of NHS England site visits, led personally by my predecessor and our National Clinical Director for Stroke Medicine, . During 2024, they visited every CSC in England to understand the local barriers and successes, support quality improvement, bring together the wider thrombectomy stakeholders to discuss collaborative opportunities and provide specific, jointly agreed, measurable actions for each centre. Each CSC was given a list of recommended actions in order to improve access to thrombectomy, focusing on pre-hospital video triage, ensuring timely diagnostic pathways, encouraging training for non-INRs and optimising all training opportunities generally to increase the workforce, developing repatriation policies to ensure that centres always have free beds, collaborating between units, and data accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake of actions.

Availability of a 24/7 thrombectomy service in the South West

NHS England’s South West region is committed to the delivery of improved diagnosis and access to appropriate time critical treatment in 24/7 operational specialist stroke units, and to increasing the availability of high-quality stroke rehabilitation in line with the National Stroke Service model.

The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Greta, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Greta Mary Ann Lewis who died on 12 July 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 June 2025 concerning the death of Greta Mary Ann Lewis on 12 July 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Greta’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Greta’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Greta’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raises the concern that there is a gap in the availability of time critical and potentially lifesaving emergency thrombectomy services in the South West, for patients who have suffered a severe stroke. You have recommended that consideration is given to the viability of a 24/7 service.

Stroke thrombectomy services are now a delegated specialised service and, since 1 April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible commissioner for the Devon region, rather than NHS England. Whilst NHS England was previously responsible for commissioning (funding) stroke thrombectomy services, the responsibility for providing this service rests with the Trusts in each region.

It is a priority for the NHS in England that all commissioned Comprehensive Stroke Centres (CSCs) provide a 24/7 thrombectomy service, regardless of a patient’s location. This has proved challenging in certain areas for a variety of reasons. In particular, the ability of services to expand and operate 24/7 is heavily reliant on recruiting the necessary specialist workforce with appropriate competencies.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

england.coronersr28@nhs.net 20 August 2025

Your Report does not detail the type of stroke suffered by Greta or the vessel which was affected, but it is relevant to note that not all ischaemic stroke patients are suitable for thrombectomy. The NHS Long Term Plan, published in January 2019, previously set an ambition for 10% of stroke patients to receive thrombectomy treatment (based on there being approximately 80,000 stroke admissions per year, and up to 8,000 of these patients potentially being eligible for thrombectomy). For those eligible patients with a large vessel occlusion to the anterior circulation, there is generally a 6 hour time interval from the onset of stroke symptoms to perform thrombectomy. Delivering treatment successfully depends on a number of factors, including timely diagnosis, conveyance to a CSC within the 6 hour timeframe, and the CSC’s operating hours and available workforce to perform the procedure.

National service development and improvements

Since January 2021, the national stroke programme has been engaging with the General Medical Council (GMC) and Royal College of Radiologists to support the development of a thrombectomy credentialing programme, including enabling non- INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and supported to perform thrombectomy and address the workforce gap. The GMC credential was published in June 2023. A substantial amount of revenue funding has since been made available to deliver the credentialing programme and the first cohort of trainees have already been enrolled and started the credential. The trainees are completing the credential alongside their full-time NHS employment in their main speciality, but it is hoped that some will be signed off within the next year. There have also been non-INRs, such as Interventional Radiologists, who have developed the skill of delivering mechanical thrombectomy and have joined the workforce in some units outside of this new route / credential.

I would also like to advise you that, alongside the national quality improvement programme, further work to ensure the ongoing service development of mechanical thrombectomy services has been supported by a programme of NHS England site visits, led personally by my predecessor and our National Clinical Director for Stroke Medicine, . During 2024, they visited every CSC in England to understand the local barriers and successes, support quality improvement, bring together the wider thrombectomy stakeholders to discuss collaborative opportunities and provide specific, jointly agreed, measurable actions for each centre. Each CSC was given a list of recommended actions in order to improve access to thrombectomy, focusing on pre-hospital video triage, ensuring timely diagnostic pathways, encouraging training for non-INRs and optimising all training opportunities generally to increase the workforce, developing repatriation policies to ensure that centres always have free beds, collaborating between units, and data accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake of actions.

Availability of a 24/7 thrombectomy service in the South West

NHS England’s South West region is committed to the delivery of improved diagnosis and access to appropriate time critical treatment in 24/7 operational specialist stroke units, and to increasing the availability of high-quality stroke rehabilitation in line with the National Stroke Service model.

The regional team regularly reviews and seeks assurance on the improvements in the service through its Regional Clinical Network, and is working with University Hospitals Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from 1 November 2025. To support this, there are multiple clinical improvement projects underway that will include training in diagnostics, pre-hospital video triage and improved clinical and ambulance pathways.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Greta, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.