Man might have survived stroke with earlier surgery, says coroner

A coroner has demanded the trust that runs the Queen's Medical Centre shows what actions it will take to address her concerns

A man who died in hospital after suffering a stroke following a diving injury might have survived if he had undergone surgery earlier, a coroner has said.

Gordon Renfrew, 36, died at the Queen's Medical Centre (QMC) in June 2022.

An inquest has concluded an operation Mr Renfrew underwent did not happen early enough because medics treating him did not follow guidelines.

The trust that runs the QMC offered condolences to his family.

Severe and extensive stroke

Nottingham coroner Dr Elizabeth Didcock has produced a prevention of future deaths report, which she has sent to Nottingham University Hospitals (NUH) NHS Trust setting out concerns she identified during Mr Renfrew's inquest.

The trust has until the end of August to respond telling her what actions it will take to address issues she raised.

She said 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 said the stroke team and the neurosurgery team had not communicated well enough.

Dr Didcock warned patients could die in the future if the problems were not solved.

A report of Mr Renfrew's inquest said he injured his neck diving from a high board on 31 May 2022 and that, along with damage to an artery, caused a blood clot and a build-up of fluid on his brain.

Dr Didcock's report said Mr Renfrew, a software engineer from Aberdeen, subsequently suffered a "severe and extensive" stroke.

He was initially taken to the Royal Derby Hospital and later transferred to the QMC on 7 June where he underwent partially successful surgery to remove the clot.

However a build-up of fluid remained in a carotid artery in his neck.

Dr Didcock said Mr Renfrew underwent a decompression craniectomy - surgery to reduce pressure caused by brain swelling - on 10 June but he died four days later.

Coroner not reassured

In a narrative conclusion, she said: "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."

In her report, the coroner told the trust: "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."

She added: "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, said: "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."