Vital care unavailable before stroke victim’s tragic death at King’s Mill Hospital to be re-thought

Peter John Asher died on February 20 at the age of 65, after first reporting numbness and tingling on his left side to a doctor at Newark Hospital’s urgent treatment centre seven days earlier, assistant coroner Neena Sharma said.

Mr Asher, known as Pete, was rightly referred to the transient ischaemic attack (TIA) clinic at King's Mill Hospital, but his referral form was lost, and his symptoms persisted.

The coroner expressed concerns that when he called the clinic the next day he may have been advised by a member of the admin team rather than the nursing staff.

The inquest heard that King's Mill doesn't offer the TIA clinic over the weekend, and shares services with Nottingham University Hospitals (NUH) NHS Trust.

Pete collapsed at his home in Farndon the following Sunday evening and was admitted to hospital early on February 17 with slurred speech, a facial droop and unsteady gait.

A scan showed he required a CT angiogram, but because this service wasn't available out of hours the uncommon, but severe, form of stroke he suffered wasn't revealed until later that day at 1.36pm, and he had sadly deteriorated in the meantime.

He was offered a thrombectomy operation to remove a blood clot at the base of his brain skull, but was told he would be left severely disabled.

Pete made the choice to decline the operation in consultation with his family, and passed away three days later.

Recording the cause of death as natural causes, the coroner noted the missed opportunities to intervene earlier but said it was "unclear" if Pete being seen within 24 hours would have changed the outcome.

The inquest heard a number of improvements have already been made at King's Mill including changing the paper-based referral process to an electronic system, and increasing TIA clinic slots from three to four. There are also plans for all calls to the TIA clinic to be handled by nurses rather than admin staff.

Sherwood Forest Hospitals NHS Foundation Trust is renegotiating its TIA service deal with NUH, and, as of September 29, the mechanical thrombectomy service will be available out-of-hours with the trust working to deliver CT angiograms out of hours.

Emma Davis, a stroke nurse specialist and Head of Service at Sherwood NHS Trust, will provide an update on the improvements in three months’ time.

Dr Simon Roe, Chief Medical Officer at Sherwood Forest Hospitals, said: “We would like to reiterate our sincere condolences to Mr Asher’s family.”

"He was the sort of person I aspire to be," said his son, Dean, at the end of the inquest last week. "He was the centre of our family. He missed out on becoming a great grandfather by a couple of days."

His children spoke warmly of a much-loved man with a "cracking sense of humour," who loved fishing, the outdoors, and rock music.