Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0304, written 17 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Jun 2025 |
|---|---|
| Reference | 2025-0304 |
| Deceased | Greta Lewis |
| Coroner | Philip Spinney |
| Coroner area | Devon, Plymouth and Torbay |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT DATED 17 JUNE 2025 IS BEING SENT TO:
NHS England.
For information:
Family of Greta Mary Ann Lewis
Chief Coroner.
1 CORONER
I am Philip SPINNEY, HM Senior Coroner, for the coroner area of The
County of Devon, Plymouth and Torbay.
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 16 July 2021 an investigation was commenced into the death of
Greta Mary Ann Lewis. The investigation concluded at the end of the
inquest held on 10-11 June 2025. The conclusion of the inquest was that
Greta Ann Lewis died as a consequence of complications of a stroke.
The short form conclusion of natural causes was recorded.
4 CIRCUMSTANCES OF THE DEATH
In March 2020 Greta Mary Ann Lewis suffered a stroke which left her with
right sided weakness. She was cared for at home by her husband with
support from a care package. In March 2021 she became unwell and
after initial treatment at home by her GP, on 12 March 2021 she was
admitted to North Devon District Hospital. Over the next weeks she was
treated in North Devon District Hospital and South Molton Community
Hospital. Despite treatment she became more unwell and frail. Her final
hospital admission was in South Molton Community Hospital where she
sadly died on 12 July 2021 due to complications caused by her stroke.
The evidence revealed that on 31 March 2020 Mrs Lewis was triaged in
the emergency department North Devon District Hospital (NDDH) at
1402hrs; it was noted that she attended following a stroke, describing the
onset of right sided facial droop and right sided arm and leg weakness at
1300hrs.
1
The hospital had been pre-alerted as this was a potentially time critical
episode.
Mrs Lewis was assessed by the duty consultant and a junior Dr. Her
symptoms and signs were noted and it was recognised that she was not
eligible for thrombolysis (clot busting medication) as she was taking
rivaroxaban. She also had a stroke severity assessment score calculated
as less than 5, this is a national score based on the symptoms and is
used to guide immediate treatment options. This score meant that she
would not benefit from a thrombectomy (the removal of clots by
mechanical retrieval). This is a procedure only performed in Derriford in
Plymouth or Bristol Hospital by an interventional neuroradiologist, this is a
specialist and highly skilled procedure.
Following a CT scan Mrs Lewis deteriorated further with worsening
weakness and the addition of speech problems. This deterioration meant
that she was now eligible for thrombectomy, however this was not
available at NDDH at that time and she had missed the window of
opportunity for a referral to Derriford which was 1500hrs. The inquest
heard evidence that at the time there was no further possibility of referral.
Evidence was also heard that the current situation is that the cut off time
for referral is now 16.30hrs.
A thrombectomy can reduce the risk of severe disability or permanent
damage caused by blood clots, restore blood flow to vital organs and can
potentially prevent limb loss or death in acute cases.
5 CORONER’S CONCERNS
The concerns relate to the provision of the thrombectomy procedure to
patients suffering with a stroke in the South West.
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) The evidence revealed that there is a gap in the availability of the
time critical and potentially lifesaving thrombectomy emergency
procedure to patients that have suffered a severe stroke in the
South West.
6 ACTION SHOULD BE TAKEN
(1) Consideration should be given to reviewing the availability of
thrombectomy procedures in the south west and consider the
2
viability of a 24/7 service.
In my opinion action should be taken to prevent future deaths and I
believe you and 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 11th August 2025 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
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. She may send a copy of this report to any person who
she 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:
Mr Philip C Spinney
HM Senior Coroner
3
2 responses 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.
Mr Philip Spinney
HM Senior Coroner
County of Devon, Plymouth & Torbay
Exeter Coroner’s Court
County Hall
Topsham Road
Exeter
EX2 4QD
coroner@devon.gov.uk
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
england.coronersr28@nhs.net
20 August 2025
Re: Regulation 28 Report to Prevent Future Deaths – Greta Mary Ann Lewis
who died on 12 July 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17
June 2025 concerning the death of Greta Mary Ann Lewis on 12 July 2021. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Greta’s family and loved ones. NHS England is keen to
assure the family and yourself that the concerns raised about Greta’s care have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Greta’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raises the concern that there is a gap in the availability of time critical and
potentially lifesaving emergency thrombectomy services in the South West, for
patients who have suffered a severe stroke. You have recommended that
consideration is given to the viability of a 24/7 service.
Stroke thrombectomy services are now a delegated specialised service and, since 1
April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible
commissioner for the Devon region, rather than NHS England. Whilst NHS England
was previously responsible for commissioning (funding) stroke thrombectomy
services, the responsibility for providing this service rests with the Trusts in each
region.
It is a priority for the NHS in England that all commissioned Comprehensive Stroke
Centres (CSCs) provide a 24/7 thrombectomy service, regardless of a patient’s
location. This has proved challenging in certain areas for a variety of reasons. In
particular, the ability of services to expand and operate 24/7 is heavily reliant on
recruiting the necessary specialist workforce with appropriate competencies.
Your Report does not detail the type of stroke suffered by Greta or the vessel which
was affected, but it is relevant to note that not all ischaemic stroke patients are suitable
for thrombectomy. The NHS Long Term Plan, published in January 2019, previously
set an ambition for 10% of stroke patients to receive thrombectomy treatment (based
on there being approximately 80,000 stroke admissions per year, and up to 8,000 of
these patients potentially being eligible for thrombectomy). For those eligible patients
with a large vessel occlusion to the anterior circulation, there is generally a 6 hour time
interval from the onset of stroke symptoms to perform thrombectomy. Delivering
treatment successfully depends on a number of factors, including timely diagnosis,
conveyance to a CSC within the 6 hour timeframe, and the CSC’s operating hours and
available workforce to perform the procedure.
National service development and improvements
Since January 2021, the national stroke programme has been engaging with the
General Medical Council (GMC) and Royal College of Radiologists to support the
development of a thrombectomy credentialing programme, including enabling non-
INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and
supported to perform thrombectomy and address the workforce gap. The GMC
credential was published in June 2023. A substantial amount of revenue funding has
since been made available to deliver the credentialing programme and the first cohort
of trainees have already been enrolled and started the credential. The trainees are
completing the credential alongside their full-time NHS employment in their main
speciality, but it is hoped that some will be signed off within the next year. There have
also been non-INRs, such as Interventional Radiologists, who have developed the skill
of delivering mechanical thrombectomy and have joined the workforce in some units
outside of this new route / credential.
I would also like to advise you that, alongside the national quality improvement
programme, further work to ensure the ongoing service development of mechanical
thrombectomy services has been supported by a programme of NHS England site
visits, led personally by my predecessor
and our National
Clinical Director for Stroke Medicine,
. During 2024, they visited every
CSC in England to understand the local barriers and successes, support quality
improvement, bring together the wider thrombectomy stakeholders to discuss
collaborative opportunities and provide specific, jointly agreed, measurable actions for
each centre. Each CSC was given a list of recommended actions in order to improve
access to thrombectomy, focusing on pre-hospital video triage, ensuring timely
diagnostic pathways, encouraging training for non-INRs and optimising all training
opportunities generally to increase the workforce, developing repatriation policies to
ensure that centres always have free beds, collaborating between units, and data
accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake
of actions.
Availability of a 24/7 thrombectomy service in the South West
NHS England’s South West region is committed to the delivery of improved diagnosis
and access to appropriate time critical treatment in 24/7 operational specialist stroke
units, and to increasing the availability of high-quality stroke rehabilitation in line with
the National Stroke Service model.
The regional team regularly reviews and seeks assurance on the improvements in the
service through its Regional Clinical Network, and is working with University Hospitals
Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from
1 November 2025. To support this, there are multiple clinical improvement projects
underway that will include training in diagnostics, pre-hospital video triage and
improved clinical and ambulance pathways.
I would also like to provide further assurances on the 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 events, such as the sad death of Greta,
are shared across the NHS at both a national and regional level and helps us to 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
NHS England
Mr Philip Spinney
HM Senior Coroner
County of Devon, Plymouth & Torbay
Exeter Coroner’s Court
County Hall
Topsham Road
Exeter
EX2 4QD
coroner@devon.gov.uk
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
england.coronersr28@nhs.net
20 August 2025
Re: Regulation 28 Report to Prevent Future Deaths – Greta Mary Ann Lewis
who died on 12 July 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17
June 2025 concerning the death of Greta Mary Ann Lewis on 12 July 2021. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Greta’s family and loved ones. NHS England is keen to
assure the family and yourself that the concerns raised about Greta’s care have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused Greta’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raises the concern that there is a gap in the availability of time critical and
potentially lifesaving emergency thrombectomy services in the South West, for
patients who have suffered a severe stroke. You have recommended that
consideration is given to the viability of a 24/7 service.
Stroke thrombectomy services are now a delegated specialised service and, since 1
April 2024, NHS Devon Integrated Care Board (ICB) has been the responsible
commissioner for the Devon region, rather than NHS England. Whilst NHS England
was previously responsible for commissioning (funding) stroke thrombectomy
services, the responsibility for providing this service rests with the Trusts in each
region.
It is a priority for the NHS in England that all commissioned Comprehensive Stroke
Centres (CSCs) provide a 24/7 thrombectomy service, regardless of a patient’s
location. This has proved challenging in certain areas for a variety of reasons. In
particular, the ability of services to expand and operate 24/7 is heavily reliant on
recruiting the necessary specialist workforce with appropriate competencies.
Your Report does not detail the type of stroke suffered by Greta or the vessel which
was affected, but it is relevant to note that not all ischaemic stroke patients are suitable
for thrombectomy. The NHS Long Term Plan, published in January 2019, previously
set an ambition for 10% of stroke patients to receive thrombectomy treatment (based
on there being approximately 80,000 stroke admissions per year, and up to 8,000 of
these patients potentially being eligible for thrombectomy). For those eligible patients
with a large vessel occlusion to the anterior circulation, there is generally a 6 hour time
interval from the onset of stroke symptoms to perform thrombectomy. Delivering
treatment successfully depends on a number of factors, including timely diagnosis,
conveyance to a CSC within the 6 hour timeframe, and the CSC’s operating hours and
available workforce to perform the procedure.
National service development and improvements
Since January 2021, the national stroke programme has been engaging with the
General Medical Council (GMC) and Royal College of Radiologists to support the
development of a thrombectomy credentialing programme, including enabling non-
INRs, such as Neurosurgeons, Stroke Physicians and Cardiologists, to be trained and
supported to perform thrombectomy and address the workforce gap. The GMC
credential was published in June 2023. A substantial amount of revenue funding has
since been made available to deliver the credentialing programme and the first cohort
of trainees have already been enrolled and started the credential. The trainees are
completing the credential alongside their full-time NHS employment in their main
speciality, but it is hoped that some will be signed off within the next year. There have
also been non-INRs, such as Interventional Radiologists, who have developed the skill
of delivering mechanical thrombectomy and have joined the workforce in some units
outside of this new route / credential.
I would also like to advise you that, alongside the national quality improvement
programme, further work to ensure the ongoing service development of mechanical
thrombectomy services has been supported by a programme of NHS England site
visits, led personally by my predecessor
and our National
Clinical Director for Stroke Medicine,
. During 2024, they visited every
CSC in England to understand the local barriers and successes, support quality
improvement, bring together the wider thrombectomy stakeholders to discuss
collaborative opportunities and provide specific, jointly agreed, measurable actions for
each centre. Each CSC was given a list of recommended actions in order to improve
access to thrombectomy, focusing on pre-hospital video triage, ensuring timely
diagnostic pathways, encouraging training for non-INRs and optimising all training
opportunities generally to increase the workforce, developing repatriation policies to
ensure that centres always have free beds, collaborating between units, and data
accuracy. 12 CSCs have received second visits during 2025, to reflect on the uptake
of actions.
Availability of a 24/7 thrombectomy service in the South West
NHS England’s South West region is committed to the delivery of improved diagnosis
and access to appropriate time critical treatment in 24/7 operational specialist stroke
units, and to increasing the availability of high-quality stroke rehabilitation in line with
the National Stroke Service model.
The regional team regularly reviews and seeks assurance on the improvements in the
service through its Regional Clinical Network, and is working with University Hospitals
Plymouth NHS Trust to establish a 24/7 thrombectomy service, to be functional from
1 November 2025. To support this, there are multiple clinical improvement projects
underway that will include training in diagnostics, pre-hospital video triage and
improved clinical and ambulance pathways.
I would also like to provide further assurances on the 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 events, such as the sad death of Greta,
are shared across the NHS at both a national and regional level and helps us to 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
NHS England
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