Mr M - Non-inquest findings

53y · Male·Bilateral ACA stroke

A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and delays in stroke team referral, he was not reviewed by the stroke team until 4:00 pm—well beyond the 4.5-hour thrombolysis window. Although a CT angiogram identified an ACA thrombus, lysis therapy was not administered. The coroner found a missed opportunity for thrombolysis due to delayed stroke team notification, though the patient's rapidly fluctuating symptoms would likely have excluded him from lysis regardless. Key lesson: establish immediate formal protocols ensuring all potential stroke patients are discussed with the stroke team at ED presentation, before definitive imaging, to optimize thrombolysis eligibility assessment.