Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0509, written 8 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2023 |
|---|---|
| Reference | 2023-0509 |
| Deceased | Jasbir Pahal |
| Coroner | Oliver Longstaff |
| Coroner area | West Yorkshire (Eastern) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Leeds Teaching Hospitals NHS Trust · Calderdale and Huddersfield NHS Foundation Trust · Yorkshire Ambulance Service NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
2.
3.
4.
5.
6.
7.
8.
9.
, Senior Service Specialist, Quarry House
, Medical Director of Commissioning, NHS England
, Clinical Lead, West Yorkshire and Harrogate Integrated Stroke
Delivery Network, Mid Yorkshire
Kent Hospitals University NHS Foundation Trust
, NHS England National Specialty Adviser for Stroke, East
Teaching Hospital NHS Foundation Trust
, National Clinical Lead for Stroke Medicine, Wirral University
, Chair, NHS West Yorkshire Integrated Care Board
, Chief Executive, NHS West Yorkshire Integrated Care Board
, Regional Director, North East and Yorkshire, NHS England
, NHS Chief Executive, NHS England
, National Medical Director of NHS England, NHS
10.
England
1
CORONER
I am Oliver Robert Longstaff, HM Area Coroner for the coroner area of West Yorkshire
(Eastern)
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 21 st December 2022 I commenced an investigation into the death of Jasbir Kaur
Pahal, aged 42 (03/09/1978). The investigation concluded at the end of the Inquest on
25th October 2023. The conclusion of the Inquest was that Jasbir's death was caused by
an ischaemic stroke. An extensive narrative conclusion is summarised in Section 4
below.
4
CIRCUMSTANCES OF THE DEATH
At 0205 hrs on Sunday 13th November 2022, Jasbir Pahal was observed to have fallen
out of bed and to be exhibiting signs indicative of having had a stroke. She was taken by
ambulance to Calderdale Royal Hospital, arriving in the Emergency Department at 0407
hrs, her arrival being delayed by the acuity of demand upon the ambulance service and
adverse weather conditions on the road. A CT scan showed an acute left middle
cerebral artery infarction.
Jasbir did not receive thrombolysis ("clot busting medication") because more than four
and a half hours had passed since she had last been seen well the previous evenino,
1
and she was hence outside the window of opportunity within which that treatment could
have been offered to her before the risks of doing so would have outweighed its
potential benefits.
Clinicians at Calderdale did not offer Jasbir a thrombectomy procedure (mechanical
removal of a clot), because she would have had to be transferred to Leeds General
Infirmary to undergo this procedure, and the protocol in place between Calderdale and
Leeds authorised such transfers to take place only between 0800 hrs and 1500 hrs on
Mondays to Fridays. Calderdale had no arrangements in place with any other hospital
for the provision of thrombectomy services outside these hours.
Following a telephone call from an Emergency Department Registrar at Calderdale, the
Royal Stoke University Hospital ("Stoke"), who operate a 24 hour thrombectomy service,
agreed to accept Jasbir as a patient, despite not having an agreement in place for the
provision of out of hours thrombectomy services to Calderdale patients.
At about the same time, the on-call stroke consultant at Leeds had spoken to one of the
Leeds interventional radiologists who agreed to accept Jasbir as a patient and to come
into Leeds to perform a thrombectomy, although there was normally no thrombectomy
service at Leeds in the early hours of Sunday morning, and there was no arrangement
between Calderdale and Leeds for an out of hours thrombectomy service for Calderdale
patients.
An ambulance crew began to take Jasbir from Calderdale to Stoke but were instructed
to turn round and bring her to Leeds, where a CT head scan showed extensive infarct
involving most of the left side of her brain, such that mechanical thrombectomy would
not improve her functional outcome. A further CT head on
November confirmed a
suspected diagnosis of malignant MCA
(middle coronary artery) syndrome,
necessitating an urgent decompressive hemicraniectomy following which she was
transferred to the intensive care unit. Active treatment was withdrawn on 27th November
and Jasbir was managed palliatively until her death on 30th November.
14th
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) Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest
to Jasbir's home address, does not offer a thrombectomy service, whether in or out of
hours.
(2) Thrombectomy is a time-sensitive procedure, requiring to be performed within six
hours of the onset of stroke symptoms to have its best chance of being successful,
although it can be performed outside of that timeframe if investigative imaging suggests
it may still be effective.
in West Yorkshire, NHS England has commissioned
(3) In common with similar arrangements applying to other district general hospital NHS
the provision of a
Trusts
thrombectomy service to Calderdale and Huddersfield NHS Foundation Trust (CHFT)
stroke patients by Leeds Teaching Hospitals NHS Trust (LTHT), whereby stroke patients
admitted to Calderdale Royal Hospital and potentially requiring thrombectomy can be
transferred for this purpose to Leeds General Infirmary (LGI).
(4) No similar service has been commissioned for CHFT stroke patients from any other
Trust.
2
(5) The existing arrangement between CHFT and L THT (and between other Trusts
within the Regional Integrated Stroke Delivery Network and L THT) operates only
between 0800 and 1500 hrs on weekdays (Monday to Friday), that is, for 35 out of 168
hours in a week (20.8%). Anyone whose nearest hyper-acute stroke unit is at a district
general hospital in West Yorkshire and who suffers a stroke outside of those hours
during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday,
does not have access to a thrombectomy service.
(6) That this level of service is inadequate is illustrated by the historical practice of
thrombectomies being performed at LGI outside of the stated hours on an occasional ad
hoc basis, dependent (among other factors) upon the availability and willingness of an
interventional neuroradiologist to attend on a voluntary basis when not on call, to
perform a potentially life-saving procedure. Among other reasons, it being considered
inappropriate that clinicians should be exposed to the moral dilemma of agreeing or
declining to perform such a life-saving procedure outside of their working or on-call
hours, L THT has as from June 2023 stopped accepting such ad hoc referrals.
(7) It is undesirable that patients such as Jasbir should be subject to the vagaries of
local arrangements when they are in urgent need of potentially life-saving treatment, and
that they should be denied access to such treatment simply by reason of their home
address.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you or your
organisation 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 26th January 2024. 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:
Trust; Leeds Teaching Hospitals NHS Trust; Yorkshire Ambulance Service NHS Trust.
; Calderdale and Huddersfield NHS Foundation
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
Signed:
81h December 2023
3
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