Recurring concern

Insufficient out-of-hours specialist stroke support

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First reported 17 Dec 2019•Latest report 4 Feb 2026

Definition

What this concern includes

Includes unavailable stroke physicians or consultants and inadequate overnight medical coverage in acute or hyper-acute stroke services where patients cannot obtain timely specialist stroke assessment, advice or treatment outside ordinary hours.

Not included

  • Excludes ordinary-hours stroke care and specialist input where an out-of-hours availability problem is not identified.
  • Excludes generic medical staffing or service-capacity deficiencies without an explicit out-of-hours stroke-care connection.
  • Excludes diagnostic, ambulance, admission or treatment failures after timely out-of-hours specialist stroke input has been obtained.
  • Excludes procedure availability, including thrombectomy capacity, where the deficient control is not access to out-of-hours stroke clinical expertise.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2019–2026

First to latest report issue date

Stated actions
6

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.

Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network1
NHS Greater Manchester Integrated Care Board1
NHS Suffolk and North East Essex Integrated Care Board1
Salford Royal Hospital1
West Suffolk NHS Foundation 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. Suffolk

    AI-generated summary

    Lauren Rae MORET-DELL · 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

    Lauren Rae Moret-Dell developed neurological symptoms, later suffered bilateral embolic strokes, and died on 10 January 2024. Concerns were raised about failures to make timely referrals to the TIA Clinic and about the lack of commissioned stroke consultant input at West Suffolk Hospital out of hours, both of which were considered to give rise to a risk of death.

    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 commissioned stroke consultant input during out-of-hours periods

    Wider context from the report

    “Evidence was heard at the Inquest that the out of hour provision for stroke care did not include West Suffolk Hospital based stroke consultant input, this being obtained either through an approach to Addenbrookes Hospital, Cambridge, or other specialist hospitals in London. Due to the distances and time involved to subsequently transport patients to specialist centres, the lack of access to stroke consultant input adversely impacts on the treatment of stroke patients during out of hours. I am concerned that the lack of commissioned stroke consultant input during out of periods at West Suffolk Hospital gives rise to a risk of death. ”

    Source location

    Lauren Rae MORET-DELL · 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

    Route thrombolysis and mechanical thrombectomy decisions for eligible patients to the telemedicine stroke consultant.

    Verbatim wording from the response

    “The Emergency Stroke Outreach Team, including a stroke specialist nurse, are present 24 hours a day, 7 days a week in hospital. In addition to this, WSFT has access to a telemedicine service, whereby a telemedicine consultant is available remotely between 17:00–08:00 hours on weekdays, and 24 hours on weekends and bank holidays. This is primarily to support thrombolysis decision-making. The consultant can remotely review scans, check a patient’s history, examination findings, and speak with the patient in real-time if required.”

    Source location

    2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
    Page 2 · response
    Published 10 February 2026

    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

    Include atypical overnight cases in the morning stroke-specialist handover and enable consultants to provide night-time advice for atypical or complex symptoms.

    Verbatim wording from the response

    “As with most district general hospitals, WSFT does not have a local stroke consultant available to discuss all stroke referrals 24/7. However, since this case, the team have incorporated in their stroke specialists’ handover, the process of mentioning any atypical cases that were reviewed”

    Source location

    2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
    Page 2 · response
    Published 10 February 2026

    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

    Review the WSFT stroke specification against current NHS standards and work with the Trust to strengthen service provision and reduce transfer delays.

    Verbatim wording from the response

    “The ICB is currently reviewing the stroke specification for WSFT in order to understand what should be in place in line with current NHS standards. We will be working with the Trust to gain assurance the service provision is strengthened to reduce risk and delays in transferring patients to specialist neurological centres.”

    Source location

    2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
    Page 3 · response
    Published 10 February 2026

    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

    Responsibility for the out-of-hours stroke consultant access concern rests with the ICB, which has responded separately.

    Verbatim wording from the response

    “Matter of Concern: Out of Hours Stroke Consultant Access”

    Source location

    2026-0059 - Response from West Suffolk NHS Foundation Trust and Suffolk and North East Essex Integrated Care Board
    Page 2 · response
    Published 10 February 2026

    Open published response

  2. 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

    Lack of clarity about the level of overnight expert stroke support

    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 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

  3. Manchester West

    AI-generated summary

    Constance Josephine Robinson · 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

    Constance Josephine Robinson died at Stepping Hill Hospital on 27 April 2019 after an intracerebral haemorrhage while receiving warfarin for atrial fibrillation, followed by aspiration pneumonia and decompensated heart failure. The report raised concerns that Fairfield Hospital and Stepping Hill Hospital were not open 24 hours a day, causing delays and additional travel for patients requiring overnight hyper acute stroke care, and highlighted the potential benefits of round-the-clock admission and medical availability.

    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 overnight Doctors in the Fairfield Hospital and Stepping Hill Hospital Hyper Acute Stroke units

    Wider context from the report

    “1. During the Inquest evidence was heard that: - i. There are 3 Hyper Acute Stroke units in Greater Manchester, namely at Fairfield Hospital in Bury, Salford Royal Hospital in Salford and Stepping Hill Hospital in Stockport. The units serve the whole of the Greater Manchester area and surrounding areas. ii. The unit at Salford Royal Hospital is open 24 hours a day 7 days a week, whereas the units at Fairfield Hospital and Stepping Hill Hospital are open from 07.00 hours to 23.00 hours each day. Accordingly, if a patient require admission to a unit between 23.00 hours and 07.00 hours, the patient must be taken to Salford Royal Hospital. In the case of the deceased, who lived in Chelford, Cheshire, she required admission to a Hyper Acute Stroke unit at 06.28 hours on the 15th April 2019 and the nearest unit to her address was at Stepping Hill Hospital. However, in view of the time of day and the fact that Stepping Hill would not be open until 07.00 hours, she had to be taken to the Salford Royal Hospital Hyper Acute Stroke unit. The journey to Salford Royal Hospital, rather than Stepping Hill Hospital, involved an additional journey of approximately 18 miles, by ambulance, with an additional travel time of approximately 30 minutes. If she had been admitted to Stepping Hill Hospital Hyper Acute Stroke unit on the 15th April 2019, she could have remained there for continuing treatment, rather than a subsequent transfer from Salford Royal Hospital to Stepping Hill Hospital on the 19th April 2019. iii. Furthermore, if a patient is in a unit at Fairfield Hospital or Stepping Hill Hospital and requires an urgent medical assessment or medical treatment between 23.00 hours and 07.00 hours, the patient must be referred to the unit at Salford Royal Hospital for advice before considering a transfer to Salford Royal Hospital between those hours. iv. Evidence given by a Consultant in Stroke Medicine at the Inquest confirmed that patients would benefit from admission to the units at Fairfield Hospital and Stepping Hill Hospital 24 hours a day 7 days a week to enable quicker assessment into a unit from all parts of Greater Manchester and to have Doctors available in each unit 24 hours a day, particularly overnight between 23.00 hours and 07.00 hours. The availability of Doctors in the units between 23.00 hours and 07.00 hours would allow immediate access to medical advice and emergency treatment and care, rather than a delay, arising from the need to refer the patient to Salford Royal Hospital. v. The Consultant also gave evidence at the Inquest that requests had been made to the Greater Manchester Stroke Operational Delivery Network for the units at Fairfield Hospital and Stepping Hill Hospital to become 24-hour units but the requests have not been granted. ”

    Source location

    Constance Josephine Robinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026