“It was recognised by all witnesses to the inquest that response to potential stroke…”
Dated 6 Jul 2015, from the coroner for Leicester City and South Leicestershire. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 31 Aug 2015. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated6 Jul 2015
- Deadline31 Aug 2015
- Published on judiciary.uk6 Jul 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospitals of Leicester NHS TrustNamed in the report as “University Hospital Leicester” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| NHS England | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— 1. It was recognised by all witnesses to the inquest that response to potential stroke symptoms should be on an emergency basis, in accordance with “FAST” criteria ie a timely response. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer. 2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission, and not be dependent on a bed, as early scanning was essential for proper diagnosis. 3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time, rather than the actual allocated 2 hour response time. 4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse: while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2015-0255
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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