Source · Prevention of Future Deaths

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Ref: 2020-0061 Date: 6 Mar 2020 Coroner: Richard Brittain Area: Inner North London Responses identified: 2 / 2 View PDF

There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.

Date 6 Mar 2020

56-day deadline 13 Mar 2023 est.

Responses identified 2 of 2

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

There is limited public awareness of stroke risks associated with cocaine use and variable access to thrombectomy services due to geographical and timing factors.

View full coroner's concerns

The MATTERS OF CONCERN following the inquest were as follows:

Concern 1, to be addressed by Public Health England
1. family raised concerns that the risk of stroke arising from cocaine use was not known to him nor his family members. They were concerned that future deaths could occur in similar circumstances and that there is limited public awareness of such risks. I share these concerns and ask that Public Health England consider this point.

Concern 2, to be addressed by NHS England
2. I heard evidence during this inquest that the availability of thrombectomy is currently variable and dependent on geographical location and timing. I am concerned that this variation will mean that future deaths will occur in similar circumstances, unless access to thrombectomy services is improved.

Responses

2 respondents

NHS England NHS / Health Body

6 Mar 2020 PDF

Action Taken

NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period, commenced in April 2017. They are developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address the shortfall in practitioners, due for roll out imminently. (AI summary)

View full response

Dear Assistant Coroner Brittain,

Re: Regulation 28 Report to Prevent Future Deaths –
- 13 June 2019

Thank you for your Regulation 28 Report dated 6 March 2020 concerning the death of on 13 June 2019. Firstly, I would like to express my deep condolences to .

The regulation 28 report concludes death was a result of cocaine use which resulted in a posterior stroke.

Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding variable geographic and timing access to thrombectomy services.

NHS England is rolling out access to thrombectomy nationally via specialised neuroscience centres over a 5-year period. This commenced in April 2017 with the mapping of services against a specification. Neuroscience centres were asked to develop implementation plans that include being able to move to a fully staffed 24/7 service over 5 years. It is recognised that there is currently an insufficient number of suitably qualified medical teams to support the expansion of thrombectomy services and this is a rate-limiting factor in terms of being able to provide comprehensive geographical coverage. NHS England is developing a bespoke training programme endorsed by the General Medical Council and Health Education England to address this shortfall in practitioners. This is due for roll out imminently. There are currently 22 providers of thrombectomy services across the country, with 6 planning to provide 24/7 access to thrombectomy and a further total of 13 who plan to provide a 7 day a week service. Regional NHS England teams are working with their service providers to develop innovative solutions that include the development of joint rotas so that patients have 24/7 access to thrombectomy within a region. As the additional trained workforce becomes available the number of centres and the number of centres able to provide 24/7 care will increase.

Dr R Brittain Assistant Coroner for Inner London North Poplar Corners Court 127 Poplar High Street London E14 0AE

National Medical Director Skipton House 80 London Road SE1 6LH

15th July 2020

NHS England and NHS Improvement Thrombectomy significantly reduces rates and levels of disability from stroke. It is estimated that up to 10% of people who suffer a stroke will be medically eligible for thrombectomy following a stroke which equates to approximately 8,000 patients per year nationally. The target in the NHS Long Term Plan is that all eligible patients will have access to thrombectomy by April 2022.

Thank you for bringing this important patient safety issue to my attention and please do not hesitate to contact me should you need any further information.

UK Health Security Agency Other

24 Apr 2020 PDF

Action Planned

PHE will ensure that stroke is included in the list of health risks of cocaine use on the FRANK website. (AI summary)

View full response

Dear Assistant Coroner R Brittain,

Re: Regulation 28: report to prevent future deaths

Thank you for your Regulation 28: report regarding and the actions that could be taken to prevent future deaths.

As you correctly point out in your report there is a causal link between cocaine use and stroke. The risk can be heightened further by health and lifestyle factors such as diabetes, hypertension or current smoking1.

While acute health problems associated with cocaine use are rare in most users, there are many potential medical and psychiatric complications associated with its use. These complications can be life threatening and include:

• cardiac problems, such as heart attacks
• pulmonary problems
• psychiatric illness, including anxiety, depression and psychosis
• neurological problems, including seizures and stroke
• gastrointestinal issues, and many others2

Cocaine use is the second most commonly used illicit drug in England. There are many sources of information about cocaine and other illicit drugs, but it is possible that the risks are misunderstood, minimised or ignored for various reasons by the public.

1 Cheng, Y. C., et al. (2016). Cocaine Use and Risk of Ischemic Stroke in Young Adults. Stroke, 47(4), 918–922. 2 Treadwell, S. D., & Robinson, T. G. (2007). Cocaine use and stroke. Postgraduate medical journal, 83(980), 389–394.

2 Information about the risks associated with cocaine use is widely available online from a range of sources. This includes the NHS Live Well website and the FRANK website, which is managed by Public Health England (PHE).

The FRANK website provides public advice and information on drugs, the risks and where to get help. In response to your request, PHE will ensure that stroke is included in the health risks of cocaine use on FRANK.

PHE is very aware of the prevalence of drug-related deaths in England. In 2018, there were 2,917 deaths related to drug misuse registered in England and Wales. In most cases, opiates were mentioned on the death certificate.

In the same year, there were 637 deaths related to cocaine, almost double the number three years earlier. However, it is not possible to distinguish between powder cocaine or crack cocaine in these reported deaths3.

Most deaths where cocaine is mentioned on the death certificate are likely to be opioid overdoses among people who used both heroin and crack cocaine.

The government has commissioned PHE to contribute to the second phase of the independent review of drugs by Professor

. Phase one of

review, which was published in February this year, recognised the increase in cocaine- related deaths.

Phase two will focus on treatment and prevention and will contain clear, evidence-based recommendations to inform policy on drug misuse treatment and prevention. It will also look at the availability and effectiveness of accurate information, education and other prevention activities about drugs, including cocaine.

Report sections

Investigation and inquest

died on 13 June 2019, aged 30 years, from the consequences of cocaine use, which resulted in a posterior stroke. I heard the inquest into his death on 22 November 2019 and recorded a narrative conclusion, as set out below: died from the consequences of cocaine use, which resulted in a posterior stroke. There were intervals to the treatment of this, although it is not possible to conclude that this contributed to his death.

Circumstances of the death

was admitted to Queen’s Hospital, Romford on 9 June 2019. The previous evening he had ingested cocaine and, in the early hours of 9th, he collapsed, unable to speak or move his left side. He was diagnosed with a basilar artery occlusion and underwent thrombolysis at 14.40 later that day. He was transferred to The National Hospital for Neurology and Neurosurgery shortly thereafter.

A thrombectomy procedure was successfully carried out, also on 9 June. However, he suffered a further deterioration and was declared brainstem dead on 13 June 2019.

Copies sent to

Barking, Havering and Redbridge University Hospitals NHS Trust and University College London Hospitals NHS Foundation Trust

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2020-0061
Date of report: 6 March 2020
Coroner: Richard Brittain
Coroner area: Inner North London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Mar 2023 (estimated).

Sent to

Department of Health and Social Care

NHS England

Part of a series

10 reports

2019-0397 0 responses identified

2022-0036 1/2

2022-0095 0 responses identified

2023-0115 0 responses identified

2024-0031 All responses identified

2025-0045 All responses identified

2025-0314 All responses identified

2026-0245 All responses identified

None 1/2

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.