Sarah Read

I am Christopher Long, Area Coroner for Lancashire and Blackburn with Darwen.

On 10 August 2022 I commenced an investigation into the death of Sarah Elizabeth Read, aged 31. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Sarah Elizabeth READ died on 7 August 2022 at Royal Preston Hospital, Preston in Lancashire. Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover. Her medical cause of death was found to be: 1a Stroke 1b Mitral Valve Replacement 1c Treated infective endocarditis II    Pregnancy

Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.

During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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) Evidence was heard that there is no provision in Lancashire for Thrombectomy Service following a stroke after 5pm and that neighbouring Trusts who provide this service are no longer able to accept patients from Lancashire. Despite efforts made to resolve this, there is nothing in place for coordination of this service regionally to ensure that this urgent lifesaving treatment is available when required after 5pm.

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