Constance Josephine Robinson · Prevention of Future Deaths report

On the 7th May 2019 I commenced an Investigation into the death of Constance Josephine Robinson (otherwise known as Josephine Robinson), 80 years, born 22nd April 1939. The Investigation concluded at the end of the Inquest on the 5th December 2019.

The Medical Cause of Death was: -

Ia Decompensated Heart Failure
Ib Atrial Fibrillation (Treated with Warfarin Therapy) and Intracerebral Haemorrhage.

The Conclusion of the Investigation was that Constance Josephine Robinson died as a consequence of naturally occurring disease exacerbated by a recognised complication of anticoagulation therapy.

1. Constance Josephine Robinson (hereinafter referred to as the “deceased”) died at Stepping Hill Hospital, Poplar Grove, Stockport, on the 27th of April 2019.

2. On the 15th of April 2019 the deceased, who was being treated with warfarin as anticoagulation therapy for atrial fibrillation, vomited and appeared agitated at her home address at Sunnybank Farm, Knutsford Road, Chelford, Cheshire. She was taken to Salford Royal Hospital, Salford, which is a Hyper Acute Stroke unit, by ambulance, where scans revealed an Intracerebral Haemorrhage. She was treated with conservative management and surgical intervention was not appropriate.

3. On the 19th of April 2019 the deceased was transferred to Stepping Hill Hospital, Stockport, which was her local Hyper Acute Stroke unit, in accordance with the Standard Operating Procedure of the Hyper Acute Stroke PathFinder V2.0.

At the Stepping Hill Hospital, she developed aspiration pneumonia, which was treated with antibiotics, but on the 27th of April 2019 she was diagnosed as suffering with Decompensated Congestive Cardiac Failure and, despite appropriate medication, she deteriorated and died.

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.

2. I request that the Greater Manchester Stroke Operational Delivery Network review the provision of Hyper Acute Stroke units in Greater Manchester, with particular reference to admission to the units at Fairfield Hospital and Stepping Hill Hospital 24 hours a day 7 days a week to enable quicker admission into a unit from all parts of Greater Manchester and the surrounding areas and to have Doctors in the units 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 to Salford Royal Hospital or to arrange a transfer to Salford Royal Hospital between those hours.

3. The reduction in the time for admission to a unit and the availability of Doctors in each unit between 23.00 hours and 07.00 hours would reduce the risks in relation to Stoke patients and prevent future deaths.