'I'm worried more people will die' - Lancashire coroner hits out at stroke care after 45 year-old's death

Lancashire coroner Christopher Long has produced a Prevention of Future Deaths Report after presiding over the inquest into the death of Michelle Mason. Ms Mason died on Saturday, June 1, 2024 at Royal Infirmary, Lancaster after suffering an Ischaemic Stroke and Basilar Artery thrombus.

Too late

She was taken to hospital by ambulance after a sudden lack of vision, vomiting and severe pain. She was reviewed by a doctor around six hours later, by which time it was too late to treat Michelle by thrombolysis. Alternative treatment by thrombectomy - a procedure to remove a blood clot from an artery - was considered which would have required Michelle to have been transferred to another hospital but no thrombectomy service was available locally. Thought was given to transferring Michelle to another hospital in the region, but it was considered to be too late by that stage for treatment and she did not recover.

Concerns

Coroner Mr Long said he believes there is a risk of future deaths if lessons are not learnt, and raised three concerns, which have been sent to NHS England, Northern Care Alliance NHS Foundation Trust and Lancashire Teaching Hospitals for a response.

The concerns are:

- NHS England national service specifications provide for a 24/7 thrombectomy service which is not currently being delivered in Lancashire and there is no clear plan to deliver that service

- There is a lack of understanding from non-stroke specialist clinicians in Lancashire as to when and where thrombectomy services are available for patients in Lancashire

- There is no mutual aid regionally, even where thrombectomy is available, clinically appropriate, it is known lack the procedure is likely to result in death and it is anticipated resources are available to complete the procedure.

Not the first time concerns have been raised

The issue has been raised almost three years after the Stroke Association called for a rapid rollout of a round-the-clock thrombectomy service in the region. The treatment - which is delivered at the Royal Preston Hospital to patients who need it from across the wider patch - is largely only during daytime hours on weekdays. In August 2022, the hope was to get a 24/7 service in place within two years, but that timeframe has been exceeded.

In May last year hospital bosses acknowledged that the operation of the service at the weekend is dependent on workforce availability. At that time they said a lack of necessary specialist staff for the service was behind delays for the 24/7 service.

Response

A Lancashire Teaching Hospitals Spokesperson said : “We offer our sincere condolences to Michelle Mason’s family. We remain committed to working with partners across the NHS with regard to the expansion of thrombectomy services and will respond constructively to the Regulation 28 report by the deadline of 31 July.”

Dr Rafik Bedair, Northern Care Alliance NHS Foundation Trust Chief Medical Officer said: “We offer our deepest condolences to Michelle Mason's loved ones during this difficult time. We are reviewing the Regulation 28 Report in detail to identify any learnings for us.”

An NHS spokesperson said: “NHS England extends its deepest sympathies to the parents and family of Michelle Mason. We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.”