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I am R Brittain, Assistant Coroner for Inner London North.

[REDACTED] 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:  [REDACTED] 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.

[REDACTED] was admitted to Queen’s Hospital, Romford on 9 June 2019. The previous evening he had ingested cocaine and, in the early hours of 9 th , 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.

During the course of this 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 following the inquest were as follows: Concern 1, to be addressed by Public Health England

1. [REDACTED] 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

1. 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.

ACTION COULD BE TAKEN In my opinion action could be taken to prevent future deaths and I believe that the addressees have the power to take such action