During the Inquest evidence was heard that:- In the course of investigations at the Royal Albert Edward Infirmary , Wigan, in relation to the failure of Doctors to respond to contact by use of the internal bleeper system during the deceaseds_admission it was_discovered that there were two 24th blind or blank spots within the precincts of the Hospital, where bleepers could not be activated: The blind or blank spots were previously unknown but were rectified so that bleepers can now be activated within all precincts of the Hospital; Evidence was given that it is believed that similar problems may exist at other Hospitals in the United Kingdom and Hospitals may be unaware of the existence of blind or blank spots within the Hospital. I have concerns that if blind or blank spots exist within Hospitals that there would be in the response of Clinicians to emergencies and patients requiring urgent treatment and in my opinion there is a risk that future deaths will occur unless action is taken: Expert evidence was considered at the Inquest from a Consultant Neurosurgeon at Salford Royal Hospital and Consultant Neurologists from London Edinburgh and Liverpool: The Experts agreed that, on the balance of probabilities, the deceased would have died when she did irrespective of her management after her admission to Royal Albert Edward Infirmary, Wigan on the 22nd December 2012. However , evidence was given that in parts of the United Kingdom, and in particular in London and Cambridge, the management of patients diagnosed with Cerebral Venous Sinus Thrombosis involved the transfer patients from District General Hospital to Regional Neuroscience Centre, as soon as reasonably practicable after a confirmed diagnosis to, allow the patient to receive treatment in Regional Centre where Specialties and Sub-Specialties exist; indluding Consultant Neurosurgeons, Consultant Neurologists and Consultant Neuroradiologists together with appropriate resources and facilities available on a 24 hour a year basis: The evidence confirmed that the treatment of Venous Thrombosis or Venous Stroke is different to the treatment f Cerebral Artery Thrombosis or Cerebral Stroke; The Experts agreed that the treatment of Cerebral Venous Sinus Thrombosis requires initial anticoagulation treatment and monitoring with regular neurological examinations ad neurological observations and, where there is significant deterioration, invasive procedures should be considered including Thrombolysis, Thrombectomy or Clot Extraction and Craniectomy, which can only be carried out at a Regional Neuroscience Centre iii_ Following the deceased's death, a full investigation in relation to the treatment of patients with Cerebral Venous Sinus Thrombosis was conducted by [ Consultant Neurologist and Clinical Director of Medical Neurosciences at Salford Royal Hospital_ together with Consultant delay the day day who

Neurologist Specialising in Cerebrovascular Diseases has produced policy and guidelines for the assessment and management of adult patients with Cerebral Venous Thrombosis in Greater Manchester , a copy of which is attached hereto. The document is extensive and refers to expectation that all patients suffering Cerebral Venous Thrombosis will be transferred from the District General Hospital to the Regional Medical Neuroscience Centre after a confirmed diagnosis of the condition to enable the patient to have the benefit of the Specialties, resources, facilities and invasive procedures only available at the Regional Centre: The evidence at the Inquest indicated that policies and quidelines similar to those produced by_ do not exist in parts of the United Kingdom: In my opinion, there is a risk that future deaths will occur unless action is taken to review the policy and guidelines for the assessment, management and treatment of patients suffering Cerebral Venous Thrombosis in all parts of United Kingdom: [ request you to consider the above concerns and to carry out a review with regard to the following: - The bleeper systems in all Hospitals in the United Kingdom to consider whether blind spots Or blank spots exist within the precincts of Hospitals to ensure coverage of all areas of each Hospital the Iocal bleeper system to enable response ad appropriate action by Clinicians in relation to bleeper calls at all times_ The policy and guidelines for assessment, management and treatment of patients diagnosed with Cerebral Venous Thrombosis in all areas of the United Kingdom, particularly with regard to the diagnosis of the condition and the transfer of patients from a District General Hospital to Regional Medical Neuroscience Centre, as soon as practicable, after a confirmed diagnosis to enable patients to have the benefit of the Specialties, resources, facilities and invasive procedures, which are only available at Regional Centre: