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Coroner says man who had stroke would have survived with earlier surgery

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A coroner has revealed that a man who died in hospital following a stroke may have survived if he had received surgery sooner.

Gordon Renfrew, 36, had a stroke following a diving injury and later died at the Queen’s Medical Centre (QMC) in June 2022.

An inquest has revealed that Mr Renfrew did not undergo surgery early enough because the medics treating him did not follow guidelines.

The BBC reports that Nottingham coroner Dr Elizabeth Didcock has produced a prevention of future deaths report, which has now been sent to Nottingham University Hospitals (NUH) NHS Trust, setting out concert she identified during Mr Renfrew’s inquest.

The trust now has until the end of August to respond to Dr Didcock and inform her of the actions they will take to address the issues raised.

Dr Didcock states that the hospital’s stroke team had not understood or followed National Institute for Health and Care Excellence (NICE) guidelines around the surgery Mr Renfrew had.

She also states that the stroke team and the neurosurgery team had not communicated well enough.

She also highlights the future risk of patients, warning that more could die if these problems remain.

Mr Renfrew’s stroke occurred after injuring his neck diving from a high board on 31 May 2022, this along with damage to an artery, caused a blood clot and a build-up of fluid on his brain.

At first, Mr Renfrew was admitted to the Royal Derby Hospital and later transferred to the QMC on 7 June where he would undergo partially successful surgery to remove the clot.

Despite this, a build-up of fluid still remained in a carotid artery in his neck. 

Mr Renfrew would then undergo a decompression craniectomy surgery to reduce pressure caused by brain swelling on June 10, but died four days later.

In her conclusion, Dr Didcock, says: “The NICE guidance on decompression craniectomy after stroke was not followed.

“There should have been detailed, early and repeated discussion with the family as to the timing of the decompression craniectomy, on 8 and 9 June 2022.

“Had this occurred it is very likely that the procedure would have been performed at an earlier time, although it is not possible to say, on a balance of probability, that this would have led to Gordon surviving what was a very severe and extensive stroke.

“There is limited evidence to date of the stroke team having a clear understanding of the NICE guidance regarding decompression craniectomy, specifically the importance of detailed careful monitoring post-stroke, with clarity about referral criteria to neurosurgery.

“The planned Standard Operating Procedure, which may set out this clarity, is not yet finalised.

“There are currently limited opportunities for joint case discussion and learning between the stroke and neurosurgical teams [and] there is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the trust.

“I am not reassured that necessary actions to address these serious issues identified are in place.”

Keith Girling, medical director for NUH, says: “We offer our sincere condolences to Mr Renfrew’s family.

“The trust acknowledged at inquest that there was a missed opportunity for earlier consideration of decompressive craniectomy following a very severe and extensive stroke.

“While the coroner could not determine that this would have prevented him sadly passing away, we are very sorry that this missed opportunity happened.

“The trust continues to reflect on Mr Renfrew’s care and how we can better improve for the future.

“We are currently working to address the concerns raised in the coroner’s Prevention of Future Deaths Report and the trust will share the response with Mr Renfrew’s family and the coroner once it is complete.”

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