Sarah Read

Christopher Long 
Lancashire with Blackburn and Darwen  
Coroner’s Court 
2 Faraday Court  
Faraday Drive 
Preston 
Lancashire 
PR2 9NB 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

16 January 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Sarah Elizabeth Read 
who died on 7 August 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
November 2023 concerning the death of Sarah Elizabeth Read on 7 August 2022. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Sarah’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Sarah’s care 
have been listened to and reflected upon.  

Your  Report  raises  the  concern  that  there  is  no  provision  in  Lancashire  for 
thrombectomy services following a stroke after 5pm and that neighbouring Trusts who 
do have this provision are no longer able to accept patients from Lancashire.  

NHS  England  has  engaged  with  colleagues  across  Lancashire  and  South  Cumbria 
(LSC)  and  Greater  Manchester  Integrated  Care  Boards  (ICBs)  to  input  into  this 
response. My colleagues from Specialised Commissioning have also reviewed your 
Report and supported this response as stroke thrombectomy services are designated 
as a specialised service.  

Mechanical thrombectomy is a relatively new technological development that is being 
developed  and  expanded  as  the  workforce  to  support  the  delivery  of  the  service 
increases 
for  adult  stroke 
thrombectomy  service  for  acute  ischaemic  stroke,  delivered  in  a  non-neuroscience 
centre 
found  here:  1868-Thrombectomy-Service-Specification.pdf 
can  be 
(england.nhs.uk). 

in  availability.  The  national  service  specification 

For  Lancashire  Teaching  Hospitals  NHS  Foundation  Trust  (LTH),  mechanical 
thrombectomy  operated  Monday  to  Friday,  8am  to  6pm  prior  to  September  2023. 
Since September 2023, and following a successful recruitment campaign,  the Trust 
has  been  able  to  increase  its  number  of  interventional  Radiologists  to  enable  the 
service to operate seven days a week, 8am to 6pm. A further expansion plan is now 
in place, with the ambition to further extend the hours to between 8am and 11pm seven 
days  a  week  from  April  2024  and  for  the  service  to  operated  24/7  from  September 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 2024. My Specialised Commissioning colleagues expect a business case from LTH 
imminently to support this plan.  

Additionally, there are building works currently underway to accommodate a second 
bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH 
are currently being supported by Specialised Commissioning with their capital bid for 
this second biplane which will also need to be supported by a successful recruitment 
campaign.  There  are  several  interdependencies  to  achieve  the  24/7  thrombectomy 
service, and the North West Specialised Commissioning Team are supporting LTH to 
understand  the  risks  and  mitigations  required.  LTH  have  confirmed  that  they  are 
committed to operating the 24/7 service by September 2024.  

Regarding your concern about access to neighbouring services, mutual aid between 
different  units  and  Trusts  is  offered  on  an  informal  and  case-by-case  basis  and  is 
reliant on capacity within the neighbouring units. The interim offer for Lancashire is in 
the  process  of  being  formalised,  led  by  the  Medical  Director  for  Specialised 
Commissioning who is working with the three units across the North West.  

Following Sarah’s death, Lancashire Teaching Hospitals undertook  an investigation 
which made the following recommendations:  

• 

Incentivised  recruitment  underway  to  meet  the  establishment  required  for 
interventional radiographers to provide a 7-day service.  

•  Thrombectomy Operational Group formed. 
•  North  West  regional  Thrombectomy  terms  of  reference  to  be  revised  and 

strengthened governance structure. 

•  Stroke  steering  group  terms  of  reference  to  be  revised  and  strengthened 

governance structure.  

•  Director level discussions with the Walton Centre and Salford Royal Hospital on 

accepting Lancashire and South Cumbria patients. 

•  Psychological support to be available for the stroke team when holding difficult 

discussions on the availability of the treatments.  

•  Ethics committee report has been presented and discussed at the Trust’s Safety 

and Learning Group.  

•  A  communication  strategy  for  patients  and  families  has  also  already  been 

agreed.  

•  Debrief of weekly cases. 

Oversight  of  these  actions  is  being  undertaken  by  Specialised  Commissioning  in 
partnership  with  LSC  ICB  to  ensure  that  they  are  successfully  embedded  and 
sustained.  

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

 
 
 
 
 
 
 
 
 
 Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director