Keith Reynolds

I am Thomas Crookes Assistant Coroner for the Coroner area of Newcastle and North Tyneside.

On 15 November 2024 I commenced an investigation into the death of Keith REYNOLDS. The investigation concluded at the end of the inquest. The conclusion of the inquest was  natural causes and recognised complications of a necessary surgical procedure.    The medical cause of death was  1a Left-Sided Cerebral Infarct 1b Thrombosis of a Left Internal Carotid Artery Stent     II         Coronary Artery Bypass Graft and Mitral Valve Repair Operation (11/11/24),  Hypertensive Heart Disease, Coronary Artery Atheroma and Mitral Valve Disease

Keith Reynolds had a history of hypertensive heart disease, coronary artery atheroma and mitral valve disease. He attended hospital on 26 October 2024 with symptoms of unstable angina for which he required an expedited coronary artery bypass and mitral valve repair.  Pre-operative assessment indicated that a carotid artery stent was required first to avoid a substantial risk of death during the bypass operation. This procedure occurred on 5 November 2024. The bypass and valve repair surgery took place on 11 November 2024. Mr  Reynolds initially appeared well but subsequently became unresponsive, having suffered an ischaemic stroke as a result of the stent becoming blocked with a blood clot. Options were considered in relation to this. Thrombolysis was contraindicated due to his recent surgery. A  mechanical thrombectomy was not possible because this service is not available out of hours but would not have been viable in any case due to Mr Reynold’s Alberta Stroke Programme  Early CT Score (ASPECTS). Mr Reynolds was therefore switched to palliative care and died  on 14 November 2024 in the Freeman Hospital, Newcastle upon Tyne as a result of the stroke.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) A mechanical thrombectomy service is not available in the region outside of 9.00am to  5.00pm due to insufficient neuroradiologists being available to run such a service. I am told  that this issue is listed on the Newcastle Upon Tyne Hospitals NHS Foundation Trust’s ‘Risk  Register’ and that a business plan has been submitted to NHS England in relation to funding for additional clinicians. However, at the present time, should patients currently require a  mechanical thrombectomy outside of the hours of 9.00am to 5.00pm, such a service would  not be available to them and this could result in their death despite this potentially being  preventable were such a service available.

In my opinion action should be taken to prevent future deaths and I believe you / your organisation have the power to take such action.