Delay in giving aspirin
16. Miss H complains Mr H did not receive aspirin until eight hours after arriving at hospital. She believes he should have received it within four hours and is concerned this delay contributed to his deterioration. We understand this was worrying for her, especially given how quickly his condition changed.
17. NICE guidance and the RCP guideline say patients with an ischaemic stroke (when a blood vessel supplying the brain becomes blocked) should receive 300mg of aspirin (a blood thinner) as soon as possible within 24 hours, unless there is a reason not to.
18. Mr H’s records show the Trust gave him aspirin at around 4pm, approximately seven hours after he arrived at the hospital. This was within the recommended 24hour timeframe. Both our advisers confirmed this timeframe was appropriate. They explained the main goal of giving aspirin in this context is to reduce the risk of recurrent stroke.
19. Taking into account the guidance and the views of our advisers, we cannot see any indications of failings on the part of the Trust in relation to the timing of the administration of aspirin to Mr H.
Inconsistent or contradictory information about the diagnosis
20. Miss H said the Trust told the family different things about her father’s stroke, including that it was a ‘minor stroke at the top of the brain’, and later it was a major stroke affecting the back of the brain. She felt this information was unclear and contradictory.
21. The clinical records show Mr H’s first CT scan on 20 March identified a small area of stroke at the back of the brain. Overnight, a repeat scan showed the stroke had progressed, and a further scan the following morning confirmed a basilar artery occlusion (a blockage in one of the main arteries supplying the brainstem).
22. Mr H’s medical records show staff updated the family as these findings became available. For example, the entry at 11.10am on 20 March records staff explained the initial CT findings and the plan for ICU.
23. The entry at 2.59pm on 21 March shows staff told the family Mr H had likely had a further stroke overnight, that a procedure to remove the clot had been attempted, and that scans showed signs of brainstem damage.
24. Further entries on 24, 25 and 26 March show staff explained the results of later scans, the unsuccessful procedure, the extent of the brainstem injury, and the reasons why the stroke was not survivable.
25. Our stroke adviser explained the type of stroke Mr H had often evolves quickly. Early scans may show only small changes, and later scans can reveal more extensive damage as the stroke progresses.
26. GMC guidance says doctors should give patients and families the information they need or want in a way they can understand and be honest about the limits of what is known at the time. The evidence shows staff shared information that reflected the scan results available at each stage of Mr H’s admission.
27. We understand why this felt confusing and distressing for the family. The evidence shows the diagnosis changed because unfortunately Mr H’s stroke progressed, not because staff gave contradictory information.
28. We recognise Miss H recalled being told the stroke was at the ‘top of the brain’, but the records and imaging consistently describe a stroke in the back part of the brain, which may have been explained in different ways at different times.
29. It is clear from speaking with Miss H and from the records that this was an extremely distressing time for her and the family.
Sedation break: timing, documentation and communication
30. Miss H said staff reduced Mr H’s sedation earlier than she had been told to expect, and this happened suddenly and without explanation. She and her family found this distressing to witness.
31. She said the nurse spoke loudly to her father, telling him he was in hospital and giving instructions such as sticking out his tongue or moving his legs. She was concerned there was no record of the sedation break in the clinical notes. She also did not know whether what happened during the sedation break had contributed to his deterioration.
32. Mr H was sedated and ventilated in ED and transferred to ICU at 11.10am on 20 March. The ICU treatment plan recorded at 2.16pm said a sedation hold would take place the following day, 21 March, which is consistent with the family’s understanding.
33. Earlier in the afternoon of 20 March, at 2.11pm, the neuroradiology consultant noted the CT findings did not explain Mr H’s low level of consciousness. This raised concern about whether the CT findings accounted for his rapid deterioration.
34. The family provided a timestamped message showing sedation was reduced later that day at 5.23pm, and the Trust acknowledged a sedation hold took place. Although staff did not document this in Mr H’s clinical notes, the family’s evidence supports that the sedation hold occurred. On the balance of probabilities, it is reasonable to say the sedation hold took place on 20 March, earlier than planned.
35. Our intensive care adviser explained sedation holds (also called sedation breaks or neurologic wakeup tests) are a standard part of intensive care practice. FICM guidance says daily sedation holds should be considered in suitable patients to allow assessment of neurological function. A sedation hold is considered safe when the patient is stable and there are no reasons to avoid it (known as contraindications). These include things like raised pressure inside the skull (intracranial pressure), seizures, or low oxygen levels.
36. The Trust said the ICU consultant decided to bring the sedation hold forward because the initial CT findings did not fully explain Mr H’s rapid fall in consciousness. Our intensive care adviser confirmed Mr H did not have any contraindications to a sedation hold at that time.
37. Miss H’s concern was the sedation break happened earlier than she had been told to expect. The clinical records show the plan changed after the neuroradiology opinion, but we have not seen evidence this change in timing was clearly communicated to the family.
38. GMC and NMC guidance say clinicians should communicate clearly with patients and families when plans change, so they understand what to expect. Because the family were not told the sedation break would happen earlier than planned, this was not in line with that guidance and caused understandable distress.
39. We have not seen evidence the decision itself about the timing was inappropriate, so we consider the lack of communication to be a shortcoming rather than indicative of a failing. The Trust has apologised for any miscommunication.
40. There is no record of the sedation hold in the clinical notes. GMC guidance requires clinicians to make clear and accurate records of assessments and changes in treatment. The Trust should therefore have documented the sedation hold.
41. The surrounding records show Mr H was stable, the decisionmaking was clinically appropriate, and there is no indication the missing entry affected the care provided. We therefore consider this a shortcoming rather than a failing.
42. Our intensive care adviser explained during a sedation hold, staff use clear, direct commands such as asking a patient to move their limbs or open their eyes. This helps assess whether the brain is sending signals to the body.
43. Staff may also remind the patient where they are, because sedated patients can be confused or remember the last place they were conscious. The Trust acknowledged the nurse may have needed to use a raised voice to gain Mr H’s attention and apologised if this came across as shouting. Our intensive care adviser confirmed this approach is part of a standard neurological assessment.
44. We were not present during the sedation hold, so we cannot know exactly how staff spoke to Mr H. Nothing in the accounts we have seen suggests the approach was inappropriate. We do recognise it caused Miss H and her family additional upset.
45. Miss H said she later read an ICU leaflet advising families not to talk to patients about traumatic events, and she felt this conflicted with what she saw. The Trust told us it no longer has this leaflet and could not confirm its content.
46. Our adviser explained orienting a patient to their surroundings during a sedation hold is appropriate and does not cause harm. This is relevant to Miss H’s concern about how staff communicated with her father during the sedation break.
47. The sedation break itself was clinically appropriate and in line with accepted intensive care practice. The lack of documentation and the lack of clear communication about the change in timing did not affect the care provided.
48. We accept this experience was traumatic for Miss H and her family. We have not seen evidence that either the timing of the sedation break or the way staff spoke to Mr H were inappropriate or unsafe.
Conflicting accounts
49. Miss H said the information staff gave the family during her father’s admission did not match what the Trust later told her in its complaint response.
50. Miss H specifically said the explanations about aspirin, thrombolysis (a clotbusting medicine), thrombectomy (a procedure to remove a clot) and the sedation break were inconsistent, which left her unsure whether the correct decisions had been made.
51. We reviewed the clinical records, the Trust’s complaint response and the advice from our clinical advisers to understand whether the Trust’s written account aligned with what happened during Mr H’s admission.
52. In its complaint response, the Trust summarised the clinical decisions made and explained the rationale for aspirin, thrombolysis, thrombectomy and the sedation hold. These explanations align with the clinical records and with the advice from our clinical advisers.
53. We have not seen evidence the Trust’s complaint response misrepresented events or contradicted the clinical records.
54. The Trust acknowledged some aspects of communication were upsetting for the family and apologised for the impact this had. It also provided fuller explanations in its complaint response than staff could give in real time during a rapidly evolving situation.
55. We considered the Trust’s complaint handling in line with the NHS Complaint Standards. These say organisations should provide a clear, person‑centred response that explains what happened, addresses each concern, and is open about any shortcomings.
56. The Trust responded to the issues raised, explained the clinical reasoning, and apologised where communication may have felt insensitive or unclear. We have not seen evidence it withheld information or gave an account that conflicted with the clinical records.
57. The evidence shows the Trust’s complaint response was consistent with the clinical records and our clinical advice. The differences relate to the evolving clinical picture and the greater level of detail available at the complaint stage, rather than the Trust providing conflicting or misleading accounts.Summary
58. We do not underestimate the impact these events have had on Miss H. The rapidly changing clinical picture, the limits of what staff could explain in real time and the differences between what staff said during admission and the Trust later wrote in the complaint response have understandably left her with unresolved doubts. We have not found indications of service failings in the care or in the Trust’s complaint response. We recognise the ongoing distress this has caused her. We hope this statement helps provide clarity about what happened and why.