REDACTED
PFD Report
All Responded
Ref: 2020-0061
All 2 responses received
· Deadline: 13 Mar 2023
Coroner's Concerns (AI summary)
There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.
View full coroner's concerns
The MATTERS OF CONCERN following the inquest were as follows:
Concern 1, to be addressed by Public Health England
1. family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members. They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks. I share these concerns and ask that Public Health England consider this point.
Concern 2, to be addressed by NHS England
2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing. I am concerned that this variation will mean that future deaths will occur in similar circumstances, unless access to thrombectomy services is improved.
Concern 1, to be addressed by Public Health England
1. family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members. They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks. I share these concerns and ask that Public Health England consider this point.
Concern 2, to be addressed by NHS England
2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing. I am concerned that this variation will mean that future deaths will occur in similar circumstances, unless access to thrombectomy services is improved.
Responses
Action Taken
NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period, commenced in April 2017. They are developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address the shortfall in practitioners, due for roll out imminently. (AI summary)
NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period, commenced in April 2017. They are developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address the shortfall in practitioners, due for roll out imminently. (AI summary)
View full response
Dear Assistant Coroner Brittain,
Re: Regulation 28 Report to Prevent Future Deaths –
- 13 June 2019
Thank you for your Regulation 28 Report dated 6 March 2020 concerning the death of on 13 June 2019. Firstly, I would like to express my deep condolences to .
The regulation 28 report concludes death was a result of cocaine use which resulted in a posterior stroke.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding variable geographic and timing access to thrombectomy services.
NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years. It is recognised that there is currently an insufficient number of suitably qualified medical teams to support the expansion of thrombectomy services and this is a rate-limiting factor in terms of being able to provide comprehensive geographical coverage. NHS England is developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address this shortfall in practitioners. This is due for roll out imminently. There are currently 22 providers of thrombectomy services across the country, with 6 planning to provide 24/7 access to thrombectomy and a further total of 13 who plan to provide a 7 day a week service. Regional NHS England teams are working with their service providers to develop innovative solutions that include the development of joint rotas so that patients have 24/7 access to thrombectomy within a region. As the additional trained workforce becomes available the number of centres and the number of centres able to provide 24/7 care will increase.
Dr R Brittain Assistant Coroner for Inner London North Poplar Corners Court 127 Poplar High Street London E14 0AE
National Medical Director Skipton House 80 London Road SE1 6LH
15th July 2020
NHS England and NHS Improvement Thrombectomy significantly reduces rates and levels of disability from stroke. It is estimated that up to 10% of people who suffer a stroke will be medically eligible for thrombectomy following a stroke which equates to approximately 8,000 patients per year nationally. The target in the NHS Long Term Plan is that all eligible patients will have access to thrombectomy by April 2022.
Thank you for bringing this important patient safety issue 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 –
- 13 June 2019
Thank you for your Regulation 28 Report dated 6 March 2020 concerning the death of on 13 June 2019. Firstly, I would like to express my deep condolences to .
The regulation 28 report concludes death was a result of cocaine use which resulted in a posterior stroke.
Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding variable geographic and timing access to thrombectomy services.
NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years. It is recognised that there is currently an insufficient number of suitably qualified medical teams to support the expansion of thrombectomy services and this is a rate-limiting factor in terms of being able to provide comprehensive geographical coverage. NHS England is developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address this shortfall in practitioners. This is due for roll out imminently. There are currently 22 providers of thrombectomy services across the country, with 6 planning to provide 24/7 access to thrombectomy and a further total of 13 who plan to provide a 7 day a week service. Regional NHS England teams are working with their service providers to develop innovative solutions that include the development of joint rotas so that patients have 24/7 access to thrombectomy within a region. As the additional trained workforce becomes available the number of centres and the number of centres able to provide 24/7 care will increase.
Dr R Brittain Assistant Coroner for Inner London North Poplar Corners Court 127 Poplar High Street London E14 0AE
National Medical Director Skipton House 80 London Road SE1 6LH
15th July 2020
NHS England and NHS Improvement Thrombectomy significantly reduces rates and levels of disability from stroke. It is estimated that up to 10% of people who suffer a stroke will be medically eligible for thrombectomy following a stroke which equates to approximately 8,000 patients per year nationally. The target in the NHS Long Term Plan is that all eligible patients will have access to thrombectomy by April 2022.
Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.
Action Planned
PHE will ensure that stroke is included in the list of health risks of cocaine use on the FRANK website. (AI summary)
PHE will ensure that stroke is included in the list of health risks of cocaine use on the FRANK website. (AI summary)
View full response
Dear Assistant Coroner R Brittain,
Re: Regulation 28: report to prevent future deaths
Thank you for your Regulation 28: report regarding and the actions that could be taken to prevent future deaths.
As you correctly point out in your report there is a causal link between cocaine use and stroke. The risk can be heightened further by health and lifestyle factors such as diabetes, hypertension or current smoking1.
While acute health problems associated with cocaine use are rare in most users, there are many potential medical and psychiatric complications associated with its use. These complications can be life threatening and include:
• cardiac problems, such as heart attacks
• pulmonary problems
• psychiatric illness, including anxiety, depression and psychosis
• neurological problems, including seizures and stroke
• gastrointestinal issues, and many others2
Cocaine use is the second most commonly used illicit drug in England. There are many sources of information about cocaine and other illicit drugs, but it is possible that the risks are misunderstood, minimised or ignored for various reasons by the public.
1 Cheng, Y. C., et al. (2016). Cocaine Use and Risk of Ischemic Stroke in Young Adults. Stroke, 47(4), 918–922. 2 Treadwell, S. D., & Robinson, T. G. (2007). Cocaine use and stroke. Postgraduate medical journal, 83(980), 389–394.
2 Information about the risks associated with cocaine use is widely available online from a range of sources. This includes the NHS Live Well website and the FRANK website, which is managed by Public Health England (PHE).
The FRANK website provides public advice and information on drugs, the risks and where to get help. In response to your request, PHE will ensure that stroke is included in the health risks of cocaine use on FRANK.
PHE is very aware of the prevalence of drug-related deaths in England. In 2018, there were 2,917 deaths related to drug misuse registered in England and Wales. In most cases, opiates were mentioned on the death certificate.
In the same year, there were 637 deaths related to cocaine, almost double the number three years earlier. However, it is not possible to distinguish between powder cocaine or crack cocaine in these reported deaths3.
Most deaths where cocaine is mentioned on the death certificate are likely to be opioid overdoses among people who used both heroin and crack cocaine.
The government has commissioned PHE to contribute to the second phase of the independent review of drugs by Professor
. Phase one of
review, which was published in February this year, recognised the increase in cocaine- related deaths.
Phase two will focus on treatment and prevention and will contain clear, evidence-based recommendations to inform policy on drug misuse treatment and prevention. It will also look at the availability and effectiveness of accurate information, education and other prevention activities about drugs, including cocaine.
Re: Regulation 28: report to prevent future deaths
Thank you for your Regulation 28: report regarding and the actions that could be taken to prevent future deaths.
As you correctly point out in your report there is a causal link between cocaine use and stroke. The risk can be heightened further by health and lifestyle factors such as diabetes, hypertension or current smoking1.
While acute health problems associated with cocaine use are rare in most users, there are many potential medical and psychiatric complications associated with its use. These complications can be life threatening and include:
• cardiac problems, such as heart attacks
• pulmonary problems
• psychiatric illness, including anxiety, depression and psychosis
• neurological problems, including seizures and stroke
• gastrointestinal issues, and many others2
Cocaine use is the second most commonly used illicit drug in England. There are many sources of information about cocaine and other illicit drugs, but it is possible that the risks are misunderstood, minimised or ignored for various reasons by the public.
1 Cheng, Y. C., et al. (2016). Cocaine Use and Risk of Ischemic Stroke in Young Adults. Stroke, 47(4), 918–922. 2 Treadwell, S. D., & Robinson, T. G. (2007). Cocaine use and stroke. Postgraduate medical journal, 83(980), 389–394.
2 Information about the risks associated with cocaine use is widely available online from a range of sources. This includes the NHS Live Well website and the FRANK website, which is managed by Public Health England (PHE).
The FRANK website provides public advice and information on drugs, the risks and where to get help. In response to your request, PHE will ensure that stroke is included in the health risks of cocaine use on FRANK.
PHE is very aware of the prevalence of drug-related deaths in England. In 2018, there were 2,917 deaths related to drug misuse registered in England and Wales. In most cases, opiates were mentioned on the death certificate.
In the same year, there were 637 deaths related to cocaine, almost double the number three years earlier. However, it is not possible to distinguish between powder cocaine or crack cocaine in these reported deaths3.
Most deaths where cocaine is mentioned on the death certificate are likely to be opioid overdoses among people who used both heroin and crack cocaine.
The government has commissioned PHE to contribute to the second phase of the independent review of drugs by Professor
. Phase one of
review, which was published in February this year, recognised the increase in cocaine- related deaths.
Phase two will focus on treatment and prevention and will contain clear, evidence-based recommendations to inform policy on drug misuse treatment and prevention. It will also look at the availability and effectiveness of accurate information, education and other prevention activities about drugs, including cocaine.
Part of a Series
9 separate reports were issued from this inquest, each sent to different organisations.
-
2019-0397
Sent to: College of Policing;No responses yet
-
2022-0036
Sent to: Broadgate General Practice; General Medical Council;1 of 2 responded
-
2022-0095
Sent to: Coventry and Warwickshire Partnership NHS Trust;No responses yet
-
2023-0115
Sent to: Children’s Commissioner for England; Department for Education; Department of Health and Social Care;No responses yet
-
2024-0031
Sent to: London Fire Brigade;All responded
-
2025-0045
Sent to: Unite Group plc;All responded
-
2025-0314
Sent to: 49 Marine Avenue Surgery; Department of Health and Social Care; Moorbridge School; North East and North Cumbria Integrated Care Board; Northumbria Healthcare NHS Foundation Trust;All responded
-
None
Sent to: Domestic Abuse Management Board Surrey PoliceSurrey County Council1 of 2 responded
This report (2020-0061) is shown above.
Sent To
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
13 Mar 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
died on 13 June 2019, aged 30 years, from the consequences of cocaine use, which resulted in a posterior stroke. I heard the inquest into his death on 22 November 2019 and recorded a narrative conclusion, as set out below: died from the consequences of cocaine use, which resulted in a posterior stroke. There were intervals to the treatment of this, although it is not possible to conclude that this contributed to his death.
Circumstances of the Death
was admitted to Queen’s Hospital, Romford on 9 June 2019. The previous evening he had ingested cocaine and, in the early hours of 9th, he collapsed, unable to speak or move his left side. He was diagnosed with a basilar artery occlusion and underwent thrombolysis at 14.40 later that day. He was transferred to The National Hospital for Neurology and Neurosurgery shortly thereafter.
A thrombectomy procedure was successfully carried out, also on 9 June. However, he suffered a further deterioration and was declared brainstem dead on 13 June 2019.
A thrombectomy procedure was successfully carried out, also on 9 June. However, he suffered a further deterioration and was declared brainstem dead on 13 June 2019.
Copies Sent To
Barking, Havering and Redbridge University Hospitals NHS Trust and University College London Hospitals NHS Foundation Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.