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Investigation and inquest
On 16 July 2021 an investigation was commenced into the death of Greta Mary Ann Lewis. The investigation concluded at the end of the inquest held on 10-11 June 2025. The conclusion of the inquest was that Greta Ann Lewis died as a consequence of complications of a stroke. The short form conclusion of natural causes was recorded.
Circumstances of the death
In March 2020 Greta Mary Ann Lewis suffered a stroke which left her with right sided weakness. She was cared for at home by her husband with support from a care package. In March 2021 she became unwell and after initial treatment at home by her GP, on 12 March 2021 she was admitted to North Devon District Hospital. Over the next few weeks she was treated in North Devon District Hospital and South Molton Community Hospital. Despite treatment she became more unwell and frail. Her final hospital admission was in South Molton Community Hospital where she sadly died on 12 July 2021 due to complications caused by her stroke.
The evidence revealed that on 31 March 2020 Mrs Lewis was triaged in the emergency department North Devon District Hospital (NDDH) at 1402hrs; it was noted that she attended following a stroke, describing the onset of right sided facial droop and right sided arm and leg weakness at 1300hrs.
The hospital had been pre-alerted as this was a potentially time critical episode.
Mrs Lewis was assessed by the duty consultant and a junior Dr. Her symptoms and signs were noted and it was recognised that she was not eligible for thrombolysis (clot busting medication) as she was taking rivaroxaban. She also had a stroke severity assessment score calculated as less than 5, this is a national score based on the symptoms and is used to guide immediate treatment options. This score meant that she would not benefit from a thrombectomy (the removal of clots by mechanical retrieval). This is a procedure only performed in Derriford in Plymouth or Bristol Hospital by an interventional neuroradiologist, this is a specialist and highly skilled procedure.
Following a CT scan Mrs Lewis deteriorated further with worsening weakness and the addition of speech problems. This deterioration meant that she was now eligible for thrombectomy, however this was not available at NDDH at that time and she had missed the window of opportunity for a referral to Derriford which was 1500hrs. The inquest heard evidence that at the time there was no further possibility of referral.
Evidence was also heard that the current situation is that the cut off time for referral is now 16.30hrs.
A thrombectomy can reduce the risk of severe disability or permanent damage caused by blood clots, restore blood flow to vital organs and can potentially prevent limb loss or death in acute cases.
Coroner’s concerns
The concerns relate to the provision of the thrombectomy procedure to patients suffering with a stroke in the South West.
(1) The evidence revealed that there is a gap in the availability of the time critical and potentially lifesaving thrombectomy emergency procedure to patients that have suffered a severe stroke in the South West.
Information checked against the published report and official responses