UK Inquiry Tracker

Gordon Renfrew

PFD Report All Responded Ref: 2023-0230

Date of Report 6 July 2023

Coroner Elizabeth Didcock

Coroner Area Nottinghamshire

Response Deadline est. 31 August 2023

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 31 Aug 2023

Coroner's Concerns (AI summary)

Inadequate communication and collaboration between stroke and neurosurgical teams, coupled with the stroke team's limited understanding of crucial NICE guidance, led to serious issues in patient care.

View full coroner's concerns

 There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust  There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised.  There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities - I note it was , (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that Gordon was reviewed by the Neurosurgical team on the early evening of the 7th June 2022 I am not reassured that necessary actions to address these serious issues identified are in place.

Responses

Nottingham University Hospital NHS / Health Body

30 Aug 2023

Action Planned
The Trust will develop joint learning strategies between Stroke, Neurosurgical, and Neuro-Radiology teams, present decompressive surgery cases at quarterly regional stroke meetings, share minutes of speciality meetings, coordinate responses to SJCRs across specialties, and continue discussing complex Mechanical Thrombectomy cases at the Mechanical Thrombectomy steering group. (AI summary)

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Dear Dr Didcock Inquest: Gordon Renfrew - Prevention of Future Death Report [PFDR] Response I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Death Notice issued on 6 July 2023 following the sad death of Mr Gordon Renfrew. May I begin with offering my sincerest condolences to Mr Renfrew’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Gordon Renfrew. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Stroke, Neurosurgery and Interventional Radiology service. The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.

Sent To

Nottinghamshire Healthcare NHS Foundation Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 31 Aug 2023

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On the 14th June 2022, I commenced an investigation into the death of Gordon Harry Renfrew. The investigation concluded at the end of the inquest on the 28th June 2023 The conclusion of the inquest was a Narrative as follows: Gordon Renfrew died on the 14th June 2022 at Queens Medical Centre Nottingham, from extensive cerebral oedema with mass effect leading to brain herniation. This was caused by a large cerebral infarction, occurring early morning on the 7th June 2022, and involving the anterior, middle and posterior lobes of the left cerebral hemisphere. The infarction was caused by a large occlusion in the left internal carotid artery in the neck, extending to the bifurcation of the internal carotid artery into the anterior and middle cerebral arteries. The occlusion was caused by arterial dissection and clot/thrombus at this site, likely caused by a combination of weakness in the arterial vessel wall from Fibromuscular Dysplasia, and a neck hyperextension injury sustained when diving from a high board on the 31st May 2022 A Mechanical Thrombectomy was undertaken on the 7th June 22, to try and remove the clot. This was partially successful, but there remained occlusion of the middle cerebral artery, with subsequent additional re-occlusion of the internal carotid artery post procedure. A Decompression Craniectomy was undertaken on the 10th June 2022, to try and reduce the effect of the severe cerebral oedema, caused by the large infarct The NICE guidance on Decompression Craniectomy after stroke, was not followed. There should have been detailed, early and repeated discussion with the family as to timing of the Decompression Craniectomy, on the 8th and 9th June 2022. Had this occurred it is very likely that the procedure would have been performed at an earlier time, although it is not possible to say, on a balance of probability, that this would have led to Gordon surviving what was a very severe and extensive stroke.

Circumstances of the Death

Gordon died on the 14th June 2022, at Queens Medical Centre (QMC), Nottingham, after a short admission. He had been transferred to QMC, from the Royal Derby Hospital for further management of a severe and extensive stroke. Detailed findings as to how he came by his death are described within a written Determination dated 28.6.23, appended to this report

Copies Sent To

2. The University Hospitals of Derby and Burton NHS Foundation Trust

Inquest Conclusion

Gordon Renfrew died on the 14th June 2022 at Queens Medical Centre Nottingham, from extensive cerebral oedema with mass effect leading to brain herniation. This was caused by a large cerebral infarction, occurring early morning on the 7th June 2022, and involving the anterior, middle and posterior lobes of the left cerebral hemisphere. The infarction was caused by a large occlusion in the left internal carotid artery in the neck, extending to the bifurcation of the internal carotid artery into the anterior and middle cerebral arteries. The occlusion was caused by arterial dissection and clot/thrombus at this site, likely caused by a combination of weakness in the arterial vessel wall from Fibromuscular Dysplasia, and a neck hyperextension injury sustained when diving from a high board on the 31st May 2022 A Mechanical Thrombectomy was undertaken on the 7th June 22, to try and remove the clot. This was partially successful, but there remained occlusion of the middle cerebral artery, with subsequent additional re-occlusion of the internal carotid artery post procedure. A Decompression Craniectomy was undertaken on the 10th June 2022, to try and reduce the effect of the severe cerebral oedema, caused by the large infarct The NICE guidance on Decompression Craniectomy after stroke, was not followed. There should have been detailed, early and repeated discussion with the family as to timing of the Decompression Craniectomy, on the 8th and 9th June 2022. Had this occurred it is very likely that the procedure would have been performed at an earlier time, although it is not possible to say, on a balance of probability, that this would have led to Gordon surviving what was a very severe and extensive stroke.