Sarah Read
PFD Report
All Responded
Ref: 2023-0460
All 1 response received
· Deadline: 12 Jan 2024
Coroner's Concerns (AI summary)
There is no provision for out-of-hours Thrombectomy Service after 5pm in Lancashire, and a lack of regional coordination means this urgent, lifesaving stroke treatment is unavailable when needed.
View full coroner's concerns
(1) 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. Despite efforts made to resolve this, there is nothing in place for coordination of this service regionally to ensure that this urgent lifesaving treatment is available when required after 5pm.
Responses
Action Taken
Since September 2023, the Trust has increased thrombectomy service availability following a recruitment campaign. An investigation was undertaken and led to the formation of a Thrombectomy Operational Group and revision of governance structures. (AI summary)
Since September 2023, the Trust has increased thrombectomy service availability following a recruitment campaign. An investigation was undertaken and led to the formation of a Thrombectomy Operational Group and revision of governance structures. (AI summary)
View full response
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Sarah Elizabeth Read who died on 7 August 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 November 2023 concerning the death of Sarah Elizabeth Read on 7 August 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sarah’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Sarah’s care have been listened to and reflected upon.
Your Report raises the concern that there is no provision in Lancashire for thrombectomy services following a stroke after 5pm and that neighbouring Trusts who do have this provision are no longer able to accept patients from Lancashire.
NHS England has engaged with colleagues across Lancashire and South Cumbria (LSC) and Greater Manchester Integrated Care Boards (ICBs) to input into this response. My colleagues from Specialised Commissioning have also reviewed your Report and supported this response as stroke thrombectomy services are designated as a specialised service.
Mechanical thrombectomy is a relatively new technological development that is being developed and expanded as the workforce to support the delivery of the service increases in availability. The national service specification for adult stroke thrombectomy service for acute ischaemic stroke, delivered in a non-neuroscience centre can be found here: 1868-Thrombectomy-Service-Specification.pdf (england.nhs.uk).
For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16 January 2024
2024. My Specialised Commissioning colleagues expect a business case from LTH imminently to support this plan.
Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.
Regarding your concern about access to neighbouring services, mutual aid between different units and Trusts is offered on an informal and case-by-case basis and is reliant on capacity within the neighbouring units. The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.
Following Sarah’s death, Lancashire Teaching Hospitals undertook an investigation which made the following recommendations:
• Incentivised recruitment underway to meet the establishment required for interventional radiographers to provide a 7-day service.
• Thrombectomy Operational Group formed.
• North West regional Thrombectomy terms of reference to be revised and strengthened governance structure.
• Stroke steering group terms of reference to be revised and strengthened governance structure.
• Director level discussions with the Walton Centre and Salford Royal Hospital on accepting Lancashire and South Cumbria patients.
• Psychological support to be available for the stroke team when holding difficult discussions on the availability of the treatments.
• Ethics committee report has been presented and discussed at the Trust’s Safety and Learning Group.
• A communication strategy for patients and families has also already been agreed.
• Debrief of weekly cases.
Oversight of these actions is being undertaken by Specialised Commissioning in partnership with LSC ICB to ensure that they are successfully embedded and sustained.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Re: Regulation 28 Report to Prevent Future Deaths – Sarah Elizabeth Read who died on 7 August 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 November 2023 concerning the death of Sarah Elizabeth Read on 7 August 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sarah’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Sarah’s care have been listened to and reflected upon.
Your Report raises the concern that there is no provision in Lancashire for thrombectomy services following a stroke after 5pm and that neighbouring Trusts who do have this provision are no longer able to accept patients from Lancashire.
NHS England has engaged with colleagues across Lancashire and South Cumbria (LSC) and Greater Manchester Integrated Care Boards (ICBs) to input into this response. My colleagues from Specialised Commissioning have also reviewed your Report and supported this response as stroke thrombectomy services are designated as a specialised service.
Mechanical thrombectomy is a relatively new technological development that is being developed and expanded as the workforce to support the delivery of the service increases in availability. The national service specification for adult stroke thrombectomy service for acute ischaemic stroke, delivered in a non-neuroscience centre can be found here: 1868-Thrombectomy-Service-Specification.pdf (england.nhs.uk).
For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16 January 2024
2024. My Specialised Commissioning colleagues expect a business case from LTH imminently to support this plan.
Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.
Regarding your concern about access to neighbouring services, mutual aid between different units and Trusts is offered on an informal and case-by-case basis and is reliant on capacity within the neighbouring units. The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.
Following Sarah’s death, Lancashire Teaching Hospitals undertook an investigation which made the following recommendations:
• Incentivised recruitment underway to meet the establishment required for interventional radiographers to provide a 7-day service.
• Thrombectomy Operational Group formed.
• North West regional Thrombectomy terms of reference to be revised and strengthened governance structure.
• Stroke steering group terms of reference to be revised and strengthened governance structure.
• Director level discussions with the Walton Centre and Salford Royal Hospital on accepting Lancashire and South Cumbria patients.
• Psychological support to be available for the stroke team when holding difficult discussions on the availability of the treatments.
• Ethics committee report has been presented and discussed at the Trust’s Safety and Learning Group.
• A communication strategy for patients and families has also already been agreed.
• Debrief of weekly cases.
Oversight of these actions is being undertaken by Specialised Commissioning in partnership with LSC ICB to ensure that they are successfully embedded and sustained.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Sent To
- NHS England
Response Status
Linked responses
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56-Day Deadline
12 Jan 2024
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 10 August 2022 I commenced an investigation into the death of Sarah Elizabeth Read, aged 31. The investigation concluded at the end of the inquest. The conclusion of the inquest was:
Sarah Elizabeth READ died on 7 August 2022 at Royal Preston Hospital, Preston in Lancashire. Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.
Her medical cause of death was found to be:- 1a Stroke 1b Mitral Valve Replacement 1c Treated infective endocarditis
II Pregnancy
4. Circumstances of the death
Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.
Sarah Elizabeth READ died on 7 August 2022 at Royal Preston Hospital, Preston in Lancashire. Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.
Her medical cause of death was found to be:- 1a Stroke 1b Mitral Valve Replacement 1c Treated infective endocarditis
II Pregnancy
4. Circumstances of the death
Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.
Copies Sent To
Lancashire Teaching Hospitals
Manchester University NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.