Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0375, written 22 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2022 |
|---|---|
| Reference | 2022-0375 |
| Deceased | Anthony Reedman |
| Coroner | Guy Davies |
| Coroner area | Cornwall and Isles of Scilly |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Plymouth NHS Trust · North Bristol NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: PUBLIC REGULATION 28: REPORT TO PREVENT FUTURE DEATHS Issued following the Inquest touching the death of Anthony James REEDMAN REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer (CEO) of NHS England Chief Executive Officer (CEO) of North Bristol NHS Trust (NBT) 1 CORONER I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 5 July 2021 I commenced an investigation into the death of Anthony James REEDMAN. The investigation concluded at the end of the inquest on 21 November 2022. The medical cause of death was as follows 1a Cerebrovascular Infarct (Complicated by Post Thrombolysis Bleed) The statutory questions (who, how, when and where) were answered as follows Anthony James Reedman died on 30 June 2021 at Royal Cornwall Hospital Truro Cornwall from a stroke contributed to by a recognized complication of thrombolysis which was administered in an unsuccessful attempt to treat the stroke. The narrative conclusion of the inquest was Mr Reedman died following a stroke, contributed to by a further brain haemorrhage following the unsuccessful attempt to treat the stroke by way of a thrombolysis. This form of treatment was the only available option for the treating physicians. The thrombolysis was administered at the extremity of the treatment window, namely 4.5 hours after the stroke. This delay in treatment was a direct consequence of an ambulance delay. The possibility of a successful outcome from the thrombolysis was significantly reduced due to the delay in treatment. 4 CIRCUMSTANCES OF THE DEATH Mr Reedman was 54 years old at the date of his death. He had no relevant medical history and was otherwise a fit, healthy and active man with a range of outdoor leisure interests. 1 Information Classification: PUBLIC He suffered a basilar artery stroke at approximately 21:45 hours whilst watching television with his wife and friends. His wife, Mrs Reedman, immediately made a 999- call requesting an ambulance. Due to an ambulance delay, it was 4.5 hours before Mr Reedman received treatment by thrombolysis, being administered at approximately 02:25 hours. Thrombolysis is the administration of "clot-busting" medicine. Clinical witnesses stated that they would have referred Mr Reedman for a thrombectomy if that option had been available. Thrombectomy involves using a specially designed clot removal device inserted through a catheter to pull or suck out the clot to restore blood flow. Thrombectomy would have provided better chances of a positive outcome. On average successful outcomes following treatment for a basilar artery stroke are 13% for thrombolysis, and 37% for thrombectomy. Thrombolysis was administered at the extreme edge of the window for that form of treatment. Thrombectomy can be performed over a slightly longer time frame than thrombolysis which is only recommended up to four and a half hours after a stroke. NHS England has approved thrombectomy for use up to six hours after stroke symptoms begin. Thrombectomy is available for limited periods of time for patients at RCHT. The Chief Medical Officer for Royal Cornwall Hospital Trust (RCHT) stated Derriford (University Hospitals Plymouth NHS Trust (UHP)) is the regional thrombectomy service for Cornwall….. At the time of Mr Reedman’s stroke in June 2021, the service operated from 0800 – 1700 Monday to Friday. UHP have recently extended their services from 17 September 2022 to include weekends/public holidays from 0700-1200, and from January 2023 are intending to extend to 1700 on weekend/public holidays. Therefore access to thrombectomy is improving but remains an issue as this is extremely time-critical intervention, but highly effective and indicative in a proportion of patients with acute stroke. Inability to access timely thrombectomy is lost opportunity to reduce the severity of neurological deficit caused by the stroke and thereby reduce the resultant disability. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) There is no thrombectomy service available 24/7 for RCHT patients. Thrombectomy is considered by clinicians to be a lifesaving procedure. On average, successful outcomes for treatment for a basilar artery stroke are 13% for thrombolysis, and 37% for thrombectomy. Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedures did not receive this procedure because it is not available 24/7 in Cornwall, unlike for example those who live in Bristol. A clinical witness described this situation as a postcode lottery. (2) The nearest 24/7 thrombectomy service is at NHS North Bristol. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is unavailable. This limits the options available to RCHT clinicians in considering treatment for stroke patients. 2 Information Classification: PUBLIC 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 January 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; • Mr Reedman’s wife and family • RCHT • SWAST I have also sent it to the UK Stroke Association who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 22 November 2022 Guy Davies 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Information Classification: CONFIDENTIAL Trust Headquarters Gate 3 Level 2, Brunel Building Southmead Hospital Westbury-on-Trym Bristol BS10 5NB Website: www.nbt.nhs.uk HM Coroner’s Service – Cornwall & The Isles of Scilly Pydar House Truro TR1 1XU Dear Mr Davies, Re: Regulation 28 following the Inquest into the Death of Mr Anthony John Reedman I write further to the Regulation 28, dated 22nd November 2022, issued as a result of the inquest into the death of Mr Anthony John Reedman. The Regulation 28 raised two key concerns, namely:- 1) There is no thrombectomy service available 24/7 for Royal Cornwall Hospital Trust (RCHT) patients. Over the last year it is estimated that 75 stroke patients in Cornwall who would otherwise be suitable for thrombectomy procedures did not receive this procedure because it is not available 24/7 in Cornwall, unlike for example those who live in Bristol. 2) The nearest 24/7 thrombectomy service is at North Bristol NHS Trust. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is available. This limits the options available to RCHT clinicians in considering treatment for stroke patients. Firstly, we would like to express our sincerest condolences to Mr Reedman’s family for their loss. Background to the thrombectomy service at North Bristol NHS Trust and thrombectomy services nationally The clinical benefits of providing a mechanical stroke thrombectomy service are well supported by evidence and thrombectomy has been formally recognised by NHS England (NHSE) as a priority for Specialised Commissioning. The NHS Long Term Plan outlines the rising demand for stroke and in particular the improvement for stroke services and requirement for thrombectomy A University of Bristol Teaching Trust. A University of the West of England Teaching Trust. Information Classification: CONFIDENTIAL expansion. Funding and commissioning of mechanical stroke thrombectomy in England is managed through the local NHS England Specialised Commissioning team. Mechanical thrombectomy is an established service at North Bristol NHS Trust and we are the second biggest (as per the SSNAP report 20/21) provider of mechanical stroke thrombectomy procedures in England. In October 2020, North Bristol saw the introduction of a 8am – 8pm seven day thrombectomy service. Despite challenges over the last few years, our thrombectomy service has continued to make significant progress, and from December 2022 this service expanded to 24/7, seven days a week funded and supported by NHSE Specialised Commissioning. This service is staffed by a combination of the following: resident nurse practitioner, resident middle grade doctor, stroke/neurology Consultant, interventionalists, neuroscience doctors, radiographers, nursing staff and anaesthetists. North Bristol is part of the Integrated Stroke Delivery Network and our thrombectomy service currently covers patients residing in the Severn region (Gloucester, Bath, Taunton, Bristol, Yeovil and Cheltenham) and Swindon and our commissioning responsibility is aligned to that geography. We recognise that out of region referrals will occur and our services will support such referrals if clinically and operationally possible. NHSE Specialised Commissioning teams are deciding on the roll out of the funding and commissioning of 24/7 mechanical stroke thrombectomy services in England. University Hospitals Plymouth NHS Trust (UHP) are responsible for tertiary stroke services for Treliske Hospital, Truro and we understand that in line with this roll out UHP are working towards offering a 24/7 seven days a week thrombectomy service from 1st October 2023. Next steps On an interim basis, as University Hospitals Plymouth transition to a 24/7 seven days a week thrombectomy service in October 2023, we will explore with them and RCHT what support North Bristol can offer by way of out of region referrals in an attempt to mitigate the risk of patients that are suitable for thrombectomy procedures not receiving this procedure. We apologise we are unable to assist any further than this given the NHSE commissioning arrangements are outside of North Bristol NHS Trust’s control. I hope you will take some assurance from this letter that we have taken seriously the concerning points you made in your Regulation 28 report. Yours sincerely, A University of Bristol Teaching Trust. A University of the West of England Teaching Trust.
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