Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network

Health and care · Health-system partnership

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First report 17 Dec 2019•Latest report 17 Dec 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to Greater Manchester Stroke Operational Delivery Network, now represented here by Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network.

    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. The report was sent to Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Neurorehabilitation & Integrated Stroke Delivery Network; that does not assign responsibility.

    PFD Monitor interpretation

    Limited overnight availability of Hyper Acute Stroke unit admission at Fairfield Hospital and Stepping Hill Hospital

    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. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026