Aspirin delay 14. When Mr R arrived at the Trust’s ED, doctors suspected he might have had a stroke and referred him immediately to its stroke outreach team and for a brain CT. An advanced nurse practitioner from the team recommended that if this showed he did not have bleeding on the brain, Mr R should have aspirin (an antiplatelet medication) as soon as possible. Antiplatelets prevent platelets in the blood from sticking together and reduce the chance of clots which cause strokes. The scan result was available at 5.42pm, showing he had not had a bleed. Staff then gave Mr R aspirin at 9pm, more than three hours later.
15. Mrs R learned the Trust did not give her husband aspirin as soon as it thought it should have done from its complaint response. The Trust said its delay in giving Mr R aspirin was likely due to miscommunication between its clinicians in different departments.
16. The Royal College of Physicians guideline, ‘National clinical guideline for stroke for UK and Ireland’ (the RCP stroke guideline) says ‘Patients with disabling acute ischaemic stroke [a stroke caused by a blockage stopping blood supply to part of the brain] should be given aspirin 300 mg as soon as possible within 24 hours (unless contraindicated)’. For patients with TIA or minor stroke it recommends antiplatelet therapy should be considered as soon as possible and within 24 hours, of which one option is aspirin.
17. Our adviser explained that Mr R could have been treated under either pathway since his symptoms had settled by the time the Trust had the result of the brain CT. This indicated he had likely experienced TIAs, rather than a more serious stroke. The Trust gave Mr R aspirin well within 24 hours of the onset of his symptoms. However, our adviser agreed with the Trust that it should have given it sooner since the RCP stroke guideline has the expectation it will be given as soon as possible.
18. The Trust’s own guideline ‘Stroke service operational policy (the Trust’s stroke guideline) mirrors the RCP stroke guideline, saying that patients with suspected ischaemic stroke or crescendo TIA should be considered for 300mg of aspirin once a brain CT has excluded bleeding.
19. The Trust did not give aspirin to Mr R ‘as soon as possible’ and therefore waiting over three hours amounts to a delay and is therefore a failing.
20. Mrs R is concerned that her husband could have avoided the more serious stroke or had a better outcome if he had received aspirin sooner. She told us this uncertainty has made her bereavement more difficult.
21. Mr R died after he had an acute basilar artery thrombosis, a type of stroke in which a blood clot blocks the blood supply to the brain stem. Our adviser explained the prognosis for this condition is very poor. More than 85% of patients will sadly die following this type of stroke, unless recanalisation is achieved (the blockage is removed by thrombolysis or thrombectomy).
22. NICE intervention evidence review ‘NG128 Stroke and transient ischaemic attack in over 16s: evidence review’ (NG128) section 1.8.1 considers the impact of giving aspirin soon after a stroke. It says the evidence does not show a reduction in recurrent stroke for the first 24 hours after the first stroke. Mr R had a recurrent stroke within 24 hours of the onset of his initial symptoms. This means that on balance he would still have had this stroke, even if he had had aspirin much sooner. Therefore, we cannot link a potentially worse outcome to the delay in receiving aspirin.
23. Mrs R is correct in her understanding that it is important to give aspirin early on. NG128 1.8.1 also says there is some evidence this reduces the risk of stroke between three and 14 days after the onset of symptoms. We can understand why she was so uncertain about whether this made a difference to her husband.
24. The Trust told Mrs R about the delay and that it did not think it would have prevent Mr R’s subsequent stroke in the same letter. In a second letter, it gave a detailed explanation about the role of aspirin in preventing stroke. It said why it did not think aspirin would have prevented Mr R’s stroke, even if doctors had given it to him when they should have. It is understandable that Mrs R was uncertain. We think the Trust’s explanations were enough to address that uncertainty and we hope our explanations add further reassurance.
25. Our NHS complaint standards says that effective complaint handling promotes a culture that is open and accountable when things go wrong. Organisations should use learning to improve their services.
26. We are pleased to see the Trust was open about its delay in treating Mr R with aspirin and identified the cause. It said this was due to a breakdown in communication between the stroke outreach team and ED staff. In its first complaint response it explained it would discuss this in its Stroke Governance meeting. By the time of its second response, it was drawing up a standard operating procedure between the stroke outreach team and the ED to ensure clarity on roles and communication. This is in line with our NHS complaint standards and with any recommendation we might consider making to improve this aspect of its service.
27. To assist us in considering an appropriate level of financial remedy we use our severity of injustice scale (our scale). We do not think Mr R would have had a different outcome. Mrs R did not become uncertain about the impact of delayed aspirin until the Trust told her about the delay. At the same time, it reassured her it did not think this could have prevented his stroke. Mrs R has remained uncertain. This is understandable given her loss. We recognise this is largely outside the Trust’s control. This impact falls at level one on our scale, which says an apology is an appropriate remedy. The Trust invited Mrs R to a resolution meeting. During this it apologised for several things which happened during her husband’s care, including the delay in providing aspirin.
28. Therefore, the Trust has done enough to put things right in line with our NHS complaint standards. We do not think it needs to take any further action.
Delay contacting the regional thrombectomy service 29. Mr R experienced a serious stroke at around 3am. The Trust transferred him to the regional thrombectomy service, provided by another NHS Trust, at around 10am. Mrs R is concerned the Trust could have contacted the thrombectomy service sooner to arrange the transfer. Therefore, she says the thrombectomy could have taken place earlier than it did. This, she thinks, could have given her husband a better outcome.
30. The Trust explained the regional thrombectomy service did not open until 8am, and therefore it could not start the process of transferring Mr R until then.
31. We considered whether the Trust took timely action when his new symptoms developed so that the regional stroke service could be contacted in a timely manner.
32. The Trust’s guideline ‘Protocol for the in-patient management of Thrombolysis and Mechanical Thrombectomy in Acute Ischaemic Stroke’ (the Trust protocol) says the pathway for (new onset) suspected stroke is an urgent brain CT to confirm stroke. If a stroke is confirmed, then medics should consider whether the patient is a candidate for thrombolysis and thrombectomy. If they are, they should be given thrombolysis and transferred to the regional thrombectomy service. Section 3.5 of the RCP stroke guideline makes a similar recommendation. It says ‘Patients with acute ischaemic stroke eligible for mechanical thrombectomy should receive prior intravenous [administered directly into the vein] thrombolysis (unless contraindicated)’.
33. The on-call stroke consultant reviewed Mr R and provided prompt advice after he developed new symptoms. They advised a new brain CT should be carried out and thrombolysis should be given with Mr R’s consent if there was no bleeding. They identified he could potentially be treated with thrombectomy, although at that time the service would not yet be open. The Trust treated Mr R promptly with thrombolysis.
34. Our adviser explained that scans should be carried out close to the decision about thrombectomy to give doctors an up-to-date picture. The Trust carried out a CT angiography to produce detailed images of blood vessels and detect blockages at around 7.20am. This was reported at 8.01am, when the regional service opened. Carrying this out sooner would not have been helpful as the images would not have been current when doctors could make the decision about whether he was suitable for thrombectomy.
35. When a patient is transferred to another service, this can only happen once that service has agreed to take them. This means the Trust had to tell the regional service that Mr R was potentially suitable to receive thrombectomy treatment and share relevant information and records. This included the various scans it had carried out. The clinicians at the regional service then had to review the information before they could decide to accept Mr R. It was only at this point that the Trust could arrange for his transfer.
36. The team treating Mr R contacted the regional service soon after the CT angiography report was available. The service accepted him and a ‘time critical transfer’ by ambulance was arranged by 9.40am. The ambulance left the Trust at around 10am. On a different day this process may have taken more or less time, depending on pressures on the Trust, the regional service, and the ambulance service. Our adviser considered this timeframe was within current practice and noted it would inevitably take time for the Trust to get Mr R ready for transport.
37. We do not think the Trust delayed contacting the regional thrombectomy service or there was a connected delay in Mr R reaching this service. Clinicians showed foresight in ordering the CT angiography at the appropriate time. While the Trust’s protocol did not advise it should do this at this time, it did this anyway. The timing of the angiography is now included in the Trust’s protocol, which was updated in November 2024.
38. Mrs R rightly recognises how time critical treatment is in the case of stroke. Her concern about possible delays has clearly caused her distress and worry. We know she has had a difficult time following the sad and unexpected loss of her husband and we hope she and her family find these explanations helpful.