Investigation and inquest
On 15 November 2024 I commenced an investigation into the death of Keith REYNOLDS. The investigation concluded at the end of the inquest. The conclusion of the inquest was natural causes and recognised complications of a necessary surgical procedure.
The medical cause of death was
1a Left-Sided Cerebral Infarct
1b Thrombosis of a Left Internal Carotid Artery Stent
II Coronary Artery Bypass Graft and Mitral Valve Repair Operation (11/11/24), Hypertensive Heart Disease, Coronary Artery Atheroma and Mitral Valve Disease
Circumstances of the death
Keith Reynolds had a history of hypertensive heart disease, coronary artery atheroma and mitral valve disease. He attended hospital on 26 October 2024 with symptoms of unstable angina for which he required an expedited coronary artery bypass and mitral valve repair. Pre-operative assessment indicated that a carotid artery stent was required first to avoid a substantial risk of death during the bypass operation. This procedure occurred on 5 November 2024. The bypass and valve repair surgery took place on 11 November 2024. Mr Reynolds initially appeared well but subsequently became unresponsive, having suffered an ischaemic stroke as a result of the stent becoming blocked with a blood clot. Options were considered in relation to this. Thrombolysis was contraindicated due to his recent surgery. A mechanical thrombectomy was not possible because this service is not available out of hours but would not have been viable in any case due to Mr Reynolds's Alberta Stroke Programme Early CT Score (ASPECTS). Mr Reynolds was therefore switched to palliative care and died on 14 November 2024 in the Freeman Hospital, Newcastle upon Tyne as a result of the stroke.
Coroner’s concerns
(1) A mechanical thrombectomy service is not available in the region outside of 9.00am to 5.00pm due to insufficient neuroradiologists being available to run such a service. I am told that this issue is listed on the Newcastle Upon Tyne Hospitals NHS Foundation Trust's 'Risk Register' and that a business plan has been submitted to NHS England in relation to funding for additional clinicians. However, at the present time, should patients currently require a mechanical thrombectomy outside of the hours of 9.00am to 5.00pm, such a service would not be available to them and this could result in their death despite this potentially being preventable were such a service available.