PFD report

Barry Myers · Prevention of Future Deaths report

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Issued 12 Mar 2025•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Insufficient funding for urgent mechanical thrombectomy provision outside daytime hours
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Establish 24/7 mutual-aid pathways to UCL and UHS for clinically indicated mechanical thrombectomy.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 March 2025.
  2. Action

    Extend the local thrombectomy service to 24/7 following implementation of the expanded service.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2025.
  3. Action

    Recruit required staff and extend the Royal Sussex County Hospital thrombectomy service to seven days a week, 12 hours a day.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The existing block funding is sufficient to expand UHSx mechanical thrombectomy operating hours.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient funding for urgent mechanical thrombectomy provision outside daytime hours

Wider context from the report

“The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation Trust. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Establish 24/7 mutual-aid pathways to UCL and UHS for clinically indicated mechanical thrombectomy.

Verbatim wording from the response

“The local service at the Royal Sussex County Hospital remains in place 08:00-16:00 hours Monday to Friday. Outside of these hours, we now have mutual aid pathways 24/7 for all of these sites to University College London Hospital (UCL) or University Hospital Southampton NHS Foundation Trust (UHS), to ensure patients have access to mechanical thrombectomy when clinically indicated.”

Source location

Response from University Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 13 March 2025

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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

Extend the local thrombectomy service to 24/7 following implementation of the expanded service.

Verbatim wording from the response

“As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.”

Source location

Response from University Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 13 March 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

Recruit required staff and extend the Royal Sussex County Hospital thrombectomy service to seven days a week, 12 hours a day.

Verbatim wording from the response

“As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.”

Source location

Response from University Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 13 March 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

Approve the business case to extend the Royal Sussex County Hospital thrombectomy service to seven days a week, 12 hours a day.

Verbatim wording from the response

“As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.”

Source location

Response from University Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 13 March 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

Continue supporting the Trust to develop evening and weekend mechanical thrombectomy operating hours.

Verbatim wording from the response

“NHS England continues to work with UHSx to support the development of services to expand their operating hours, to include evenings and weekends (operating seven days a week). This is possible within the current level of funding received by the Trust, however it is recognised that the current financial position of the Trust means that there are significant challenges to being able to identify the funds internally to expand the service at this time.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 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

Support development of mutual aid arrangements with other centres so patients can access out-of-hours mechanical thrombectomy when the local service is unavailable.

Verbatim wording from the response

“Over the past year, NHS England has been supporting UHSx with developing mutual aid arrangements with other centres offering mechanical thrombectomy services, for when the UHSx service is not available. Alternative pathways have recently been agreed for patients in the west of Sussex (accessing care from St Richard’s Hospital and Winchester Hospital) to be referred directly to University Hospital Southampton NHS Foundation Trust for out of hours mechanical thrombectomies. Patients from other part of Sussex (accessing care under East Sussex Healthcare NHS Trust, or University Hospitals Sussex NHS Foundation Trust (UHS) Eastbourne, Brighton and Hove) are referred to the University College London Hospital (UCLH) out of hours. Both the UCLH and UHS service are currently operating 24/7.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 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

Fund the purchase of a second bi-plane scanner to support extended hours and faster access when the existing scanner is occupied.

Verbatim wording from the response

“share the learning from other centres who have expanded their services over recent years. NHS England has also funded the purchase of a second bi-plane scanner to allow extended operating hours and enable more rapid access to mechanical thrombectomy when the current bi-plane scanner is being used for other elective treatments.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 2025

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

The existing block funding is sufficient to expand UHSx mechanical thrombectomy operating hours.

Verbatim wording from the response

“NHS England continues to work with UHSx to support the development of services to expand their operating hours, to include evenings and weekends (operating seven days a week). This is possible within the current level of funding received by the Trust, however it is recognised that the current financial position of the Trust means that there are significant challenges to being able to identify the funds internally to expand the service at this time.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 2025

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

UHSx cannot yet expand mechanical thrombectomy hours because of operational, workforce and internal funding challenges.

Verbatim wording from the response

“UHSx has not been able to expand their operating hours from the initial hours they started the service with (Monday-Friday, 08:00-16:00) due to operational and workforce challenges. Whilst there has been an increase in the number of mechanical thrombectomies undertaken each year at UHSx, the levels of activity are not yet at the value set within the block funding arrangement.”

Source location

Response from NHS England
Page 1 · response
Published 13 March 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Install a second bi-planar at the Royal Sussex County Hospital for prioritised mechanical thrombectomy patients.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2025.
  2. 2

    Work with the Trust on targeted safety and quality improvements for specialised commissioning services, including mechanical thrombectomy.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2025.
  3. 3

    Work with the Trust to assess workforce models and share learning from centres that expanded mechanical thrombectomy services.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2025.
  4. 4

    Discuss Regulation 28 reports through the national working group and share patient-safety learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 March 2025.
  5. 5

    Work with regional commissioners and providers to develop a South East mechanical thrombectomy strategy covering mutual aid and increased treatment capacity.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 March 2025.

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

Install a second bi-planar at the Royal Sussex County Hospital for prioritised mechanical thrombectomy patients.

Verbatim wording from the response

“In addition, we are in the process of installing the second bi-planar at the Royal Sussex County Hospital. We expect this to be operational by September 2025 and this will be prioritised for patients undergoing mechanical thrombectomy. We are aiming to extend the local service by this time, dependent on staff recruitment.”

Source location

Response from University Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 13 March 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

Work with the Trust on targeted safety and quality improvements for specialised commissioning services, including mechanical thrombectomy.

Verbatim wording from the response

“The further development of mechanical thrombectomy services at UHSx is encompassed within a targeted piece of work with UHSx to improve the safety and quality of services for patients accessing some specialised commissioning services, which include mechanical thrombectomy services. UHSx are also continuing to work with the Sussex Integrated Stroke Delivery Network on projects to optimise the pathway for stroke patients, enabling rapid identification of patients suitable for a mechanical thrombectomy, including the use of digital diagnostic and referral systems.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 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

Work with the Trust to assess workforce models and share learning from centres that expanded mechanical thrombectomy services.

Verbatim wording from the response

“UHSx has recently approved and commenced recruitment of key interventional radiology nursing posts as part of the plans to expand the service’s operating hours. NHS England is working with the Trust to consider different workforce models and”

Source location

Response from NHS England
Page 1 · response
Published 13 March 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

Discuss Regulation 28 reports through the national working group and share patient-safety learning across national and regional NHS services.

Verbatim wording from the response

“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 Barry, 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.”

Source location

Response from NHS England
Page 3 · response
Published 13 March 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

Work with regional commissioners and providers to develop a South East mechanical thrombectomy strategy covering mutual aid and increased treatment capacity.

Verbatim wording from the response

“NHS England is working with the local Integrated Care Boards (ICBs) and mechanical thrombectomy providers across the South East to develop a mechanical thrombectomy strategy for the region, which includes ensuring that robust mutual aid arrangements are in place in case of any service disruption, and working with providers on developing services to increase the numbers of patients receiving mechanical thrombectomy treatment for strokes, to optimise the outcome for patients. This work has been supported by two NHS England visits to UHSx, led by myself and the National Clinical Director for Stroke, on 7th August 2024, and most recently on 4th April of this year, to ensure ongoing service development of mechanical thrombectomy services.”

Source location

Response from NHS England
Page 2 · response
Published 13 March 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026