Recurring concern

Unsafe coordination of thrombolysis care

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First reported 8 Dec 2017•Latest report 14 Nov 2025

Definition

What this concern includes

Includes failures of guidance, transfer coordination, treatment initiation, specialist decision-making or other controls specifically dedicated to the thrombolysis pathway.

Not included

  • Excludes generic staffing, training, documentation or communication failures not explicitly tied to thrombolysis care.
  • Excludes failures concerning unrelated treatments, transfers or clinical pathways.
  • Excludes isolated clinical decisions that do not concern the coordination or delivery of thrombolysis care.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2017–2025

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Association of Ambulance Chief Executives1
NHS Greater Manchester Integrated Care Board1
Royal Sussex County Hospital1
St George'S University Hospitals NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1
Yorkshire Ambulance Service NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Margaret Crooks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Crooks attended Stepping Hill Hospital after being diagnosed with a stroke and received intravenous thrombolysis. She developed a large bleed attributed to the thrombolysis, and died at Salford Royal Hospital on 20 February 2025. The report identified confusion about the level of overnight specialist stroke support and concern that time-critical treatment advice was not provided promptly or with stroke consultant input.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely stroke consultant input for thrombolysis complications

    Wider context from the report

    “The Inquest was told that Greater Manchester has a stroke network. In essence there are 3 hospitals that are stroke centres, and that Stepping Hill is one of them. However, under the system overnight (after 11.30pm) Salford Royal provides all expert stroke input into the other 2 centres. This is because the assessment of need has identified that the presence of stroke provision overnight at the other 2 centres is not justified by the demand. During the course of the inquest there appeared to be some confusion amongst some of the stroke clinicians who support the work as to the level of support that was to be provided by Salford Royal overnight to Stepping Hill. This creates a risk that expert and complex advice is not given as quickly as necessary. The evidence was that many of the decisions in relation to how to deal with complications arising from thrombolysis in a stroke patient need to be made by a stroke consultant and are time critical. In Mrs Crooks case the evidence of the stroke team was that they would have expected the overnight team based at Salford to have advised the Stepping Hill medical team to start giving treatment before the transfer to Salford Royal. The advice whilst Mrs Crooks was at Stepping Hill appears to have been given by the stroke Registrar at Salford rather than with input from the stroke consultant. In Mrs Cooks’ case it could not be confirmed that the outcome would have been different if she had received earlier treatment or there had been input earlier from a stroke consultant but in other cases a delay could change the outcome. ”

    Source location

    Margaret Crooks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the standard operating procedure governing out-of-hours specialist stroke advice.

    Verbatim wording from the response

    “• Reviewed the current Standard Operating Procedure (SOP) between CSCs and the other Greater Manchester stroke centres that details the protocol to be followed in terms of provision of hyper acute advice out of hours.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Agree amended wording defining specialist stroke advice in the standard operating procedure.

    Verbatim wording from the response

    “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain formal network governance approval for the amended standard operating procedure wording.

    Verbatim wording from the response

    “On review, it is evident that information for clinicians could be improved. In order to ensure complete clarity for clinicians involved in seeking and providing specialist advice in future, the network proposes adding further detail in the current SOP as to what constitutes specialist stroke advice. Discussions are underway to agree the amended wording which will be formally approved via the network’s governance. We anticipate this will be completed by the end of February 2026, when we will report again to you with updated information.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 18 November 2025

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Mark Bennett · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mark Bennett died at Meadowhall Shopping Centre Sheffield on 14 April 2022 from a pulmonary embolism following a leg injury and immobility after a trip in the London Underground. During the inquest, concerns were raised that ambulance guidance was unclear about how long resuscitation should continue and when patients should be taken to hospital for possible thrombolysis, and that this might place future patients at risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of guidance or protocols on when to take patients to hospital for thrombolysis

    Wider context from the report

    “5.1 I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis. ”

    Source location

    Mark Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing JRCALC guidance provides resuscitation, termination, thrombolysis and conveyance instructions for ambulance clinicians.

    Verbatim wording from the response

    “With regard to the UK ambulance service clinical practice guidelines (the “JRCALC guidelines”). The JRCALC guidelines are in regular use by ambulance clinicians across the UK and guide decisions on the assessment and management of a wide range of clinical presentations. The guidelines have specific sections on many aspects of resuscitation. The guidelines are based on clinical evidence and are aligned to other published guidance such as from the Resuscitation Council UK (RCUK) and NICE. One particularly guideline is called: Termination of Resuscitation and Verification of Death in Adults. It contains guidance on those conditions that are unequivocally associated death, and other conditions where resuscitation may be withheld or discontinued. The guidance was updated in October 2022 and the decision to terminate resuscitation was increased from 20 minutes to 30 minutes.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 1 · response
    Published 22 November 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing JRCALC and Resuscitation Council guidelines clearly address resuscitation and potentially reversible causes, including suspected pulmonary embolism.

    Verbatim wording from the response

    “Nationally, ambulance clinicians follow standard clinical practice guidelines developed and managed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) on behalf of the Association of Ambulance Chief Executives (AACE). These are universally referred to as the JRCALC Guidelines. Guidelines relating to the management of cardiac arrest follow the Resuscitation Council (UK) guidelines. The guidelines are clear on the delivery of Advanced Life Support (ALS) and when to consider that to commence or continue resuscitation attempts would be futile. YAS clinicians have the ability at all times to access these guidelines via an app on a personal issue YAS mobile phone.”

    Source location

    Response from Yorkshire Ambulance Service
    Page 1 · response
    Published 22 November 2023

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Roger Albert Saxby · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roger Albert Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in starting thrombolysis after arrival at a receiving vascular hub

    Wider context from the report

    “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

    Source location

    Roger Albert Saxby · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Thrombolysis was commenced as promptly as reasonably possible after arrival, without compromising patient safety.

    Verbatim wording from the response

    “Mr Saxby arrived at St George’s at 16:45 hours on Friday 28 July 2017 and underwent thrombolysis at 19:00 hours. Colleagues from both the vascular and interventional radiology (IR) teams have reviewed Mr. Saxby’s pathway and they are absolutely confident that thrombolysis in this case was commenced as soon as it was safe and practical to do so. Mr. Saxby had to be assessed and clerked, and prepared for theatre including being consented for the procedure. Having reviewed the theatre list for 28 July 2017, the IR service has confirmed that the IR suite was not available to take a patient at around 17:00 hours in any event as they had an on-going case at the time. As soon as the case was completed and the IR suite was cleaned and prepared for the next case, the IR on call team sent for Mr. Saxby. Mr Saxby arrived in the IR suite at 18:30 hours.”

    Source location

    2017-0365-Response-by-St-Georges-Universty-Hospital
    Page 1 · response
    Published 11 February 2018

    Open published response
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Data last updated 7 September 2026