PFD report

Sarah Elizabeth READ · Prevention of Future Deaths report

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Issued 17 Nov 2023•Lancashire and Blackburn with Darwen

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised2

  1. Failure of regional coordination of thrombectomy services
    Part of recurring concern: Insufficient regional capacity and mutual aid for time-critical specialist care
  2. Lack of thrombectomy service provision in Lancashire after 5pm
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.6

  1. Action

    Extend Lancashire thrombectomy service hours to 8am–11pm seven days a week from April 2024.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
  2. Action

    Formalise the interim mutual-aid arrangement for Lancashire patients with three North West thrombectomy units.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
  3. Action

    Support Lancashire Teaching Hospitals in identifying risks and mitigations for achieving 24/7 thrombectomy provision.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.

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

Failure of regional coordination of thrombectomy services

Wider context from the report

“(1) Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire. Despite efforts made to resolve this, there is nothing in place for coordination of this service regionally to ensure that this urgent lifesaving treatment is available when required after 5pm. ”

Is this part of a recurring concern?

Yes — Insufficient regional capacity and mutual aid for time-critical specialist care.

Open source report

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

Lack of thrombectomy service provision in Lancashire after 5pm

Wider context from the report

“(1) Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire. Despite efforts made to resolve this, there is nothing in place for coordination of this service regionally to ensure that this urgent lifesaving treatment is available when required after 5pm. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Extend Lancashire thrombectomy service hours to 8am–11pm seven days a week from April 2024.

Verbatim wording from the response

“For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September”

Source location

Response from NHS England
Page 1 · response
Published 22 November 2023

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

Formalise the interim mutual-aid arrangement for Lancashire patients with three North West thrombectomy units.

Verbatim wording from the response

“Regarding your concern about access to neighbouring services, mutual aid between different units and Trusts is offered on an informal and case-by-case basis and is reliant on capacity within the neighbouring units. The interim offer for Lancashire is in the process of being formalised, led by the Medical Director for Specialised Commissioning who is working with the three units across the North West.”

Source location

Response from NHS England
Page 2 · response
Published 22 November 2023

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 Lancashire Teaching Hospitals in identifying risks and mitigations for achieving 24/7 thrombectomy provision.

Verbatim wording from the response

“Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.”

Source location

Response from NHS England
Page 2 · response
Published 22 November 2023

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

Establish a 24/7 Lancashire thrombectomy service by September 2024, subject to required capacity and approvals.

Verbatim wording from the response

“For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September”

Source location

Response from NHS England
Page 1 · response
Published 22 November 2023

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 Lancashire Teaching Hospitals’ capital bid and building works for a second bi-plane angiogram unit.

Verbatim wording from the response

“Additionally, there are building works currently underway to accommodate a second bi-plane angiogram unit, which are expected to be completed by Summer 2024. LTH are currently being supported by Specialised Commissioning with their capital bid for this second biplane which will also need to be supported by a successful recruitment campaign. There are several interdependencies to achieve the 24/7 thrombectomy service, and the North West Specialised Commissioning Team are supporting LTH to understand the risks and mitigations required. LTH have confirmed that they are committed to operating the 24/7 service by September 2024.”

Source location

Response from NHS England
Page 2 · response
Published 22 November 2023

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

Increase interventional radiologist capacity to operate thrombectomy services seven days a week from 8am to 6pm.

Verbatim wording from the response

“For Lancashire Teaching Hospitals NHS Foundation Trust (LTH), mechanical thrombectomy operated Monday to Friday, 8am to 6pm prior to September 2023. Since September 2023, and following a successful recruitment campaign, the Trust has been able to increase its number of interventional Radiologists to enable the service to operate seven days a week, 8am to 6pm. A further expansion plan is now in place, with the ambition to further extend the hours to between 8am and 11pm seven days a week from April 2024 and for the service to operated 24/7 from September”

Source location

Response from NHS England
Page 1 · response
Published 22 November 2023

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.2

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning nationally and regionally.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
  2. 2

    Oversee the identified thrombectomy safety actions with Lancashire and South Cumbria partners to ensure they are embedded and sustained.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.

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 all Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning nationally and regionally.

Verbatim wording from the response

“I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 22 November 2023

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

Oversee the identified thrombectomy safety actions with Lancashire and South Cumbria partners to ensure they are embedded and sustained.

Verbatim wording from the response

“Following Sarah’s death, Lancashire Teaching Hospitals undertook an investigation which made the following recommendations:”

Source location

Response from NHS England
Page 2 · response
Published 22 November 2023

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