6 Dec 2018 Simon Healey · Prevention of Future Deaths report Berkshire
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Concerns raised 4 Lack of full critical care capacity in private hospitals View source Lack of specialised nursing expertise for post-operative patients at risk of leak or sepsis View source Failure of escalation arrangements to provide emergency assessment by critical care-competent staff View source Failure to conduct adequate and candid investigations of serious clinical events View source See 1 more concern
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Simon Healey · Prevention of Future Deaths report
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Report summary
Simon Healey underwent right hemi-colectomy on 1 August 2017 and died on 10 August 2017 after an anastomotic leak led to faecal peritonitis, E. coli septicaemia and organ failure. The principal concerns were missed opportunities to detect the leak and sepsis earlier, inadequate escalation of care under NEWS protocols, the suitability of private hospitals’ staffing and facilities for such procedures, and an inadequate hospital investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Healthcare Providers Network; that does not assign responsibility.
PFD Monitor interpretation Lack of full critical care capacity in private hospitals
Wider context from the report “(1) I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell. Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position. The Royal College of Physicians NEWS trigger thresholds have been adopted almost verbatim by this hospital, save for the category relating to the sickest patients. Whilst the trigger thresholds in the RCP documents do need to be tailored to the organisation in question, it would appear, based on the information I have been provided with, that something well below an “emergency response” can be provided in this hospital, and perhaps also the wider private sector . RCP guidelines clearly require “emergency assessment by a team with critical care competencies”. The escalation policy at Ramsay Healthcare hospitals currently (for a patient scoring 7 or above) is for the registered nurse “to immediately inform the RMO and named consultant. The named consultant to attend urgently and review the patient and agree action to be taken. Consider transfer of care to a level 2 or 3 clinical care facility i.e. HDU or ICU”. This policy clearly anticipates initial review by a consultant, outside the hospital, who may well not be available to attend on an emergency basis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Healthcare Providers Network; that does not assign responsibility.
PFD Monitor interpretation Lack of specialised nursing expertise for post-operative patients at risk of leak or sepsis
Wider context from the report “(2) We heard evidence that Berkshire Independent Hospital has performed 5 operations like this between 2016 and 2018, including Simon’s operation. Whilst the surgeon had experience of the procedure in the NHS, post-operative management is carried out in a general ward, caring for patients from a range of specialities. Nursing staff in this context may well never have cared for a patient after this operation, and not be familiar with the signs and symptoms to be aware of in particular, to alert clinical teams to signs which point towards leak and/or sepsis. I accept that private hospitals cannot realistically provide separate specialist wards for this. It does however raise the question of whether private hospitals should be carrying out procedures like this without specialised nurses and without facilities to escalate care without delay.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Healthcare Providers Network; that does not assign responsibility.
PFD Monitor interpretation Failure of escalation arrangements to provide emergency assessment by critical care-competent staff
Wider context from the report “(1) I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell. Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position. The Royal College of Physicians NEWS trigger thresholds have been adopted almost verbatim by this hospital, save for the category relating to the sickest patients. Whilst the trigger thresholds in the RCP documents do need to be tailored to the organisation in question, it would appear, based on the information I have been provided with, that something well below an “emergency response” can be provided in this hospital, and perhaps also the wider private sector. RCP guidelines clearly require “emergency assessment by a team with critical care competencies”. The escalation policy at Ramsay Healthcare hospitals currently (for a patient scoring 7 or above) is for the registered nurse “to immediately inform the RMO and named consultant. The named consultant to attend urgently and review the patient and agree action to be taken. Consider transfer of care to a level 2 or 3 clinical care facility i.e. HDU or ICU” . This policy clearly anticipates initial review by a consultant, outside the hospital, who may well not be available to attend on an emergency basis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Independent Healthcare Providers Network; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct adequate and candid investigations of serious clinical events
Wider context from the report “(3) The final concern relates to Berkshire Independent Hospital only. The hospital investigation into these events was inadequate , particularly in relation to the decision-making of the key player in this matter, ████████ There are 2 sentences in the report regarding his involvement , and it would appear, a simple acceptance of his view that this was no more than a recognised complication of this procedure . This organisation will not learn from said cases like this if their own investigations are inadequate . We heard some evidence of review of this procedure, but I suggest that this is considered very carefully, to ensure that the risk of future deaths is reduced by adequate and candid investigation.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Verbatim wording from the response “In order to support this agenda item, IHPN will undertake a scoping exercise on how providers assure themselves of levels of staff awareness of NEWS and on sepsis training. This will assist us to identify if these two elements of this unfortunate case are indeed reflected across the wider sector.” Source location 2018-0378-Response-by-IHPN
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss escalation policies in independent acute hospitals with the CQC.
Verbatim wording from the response “IHPN’s formal engagement with the CQC includes frequent catch-up meetings to discuss quality themes across the sector. It also comprises joint CQC-IHPN seminars where providers share best practice and learn from each other. Previous seminars have focused on safety and well-led. We will be discussing escalation policies in independent acute hospitals with the CQC in February.” Source location 2018-0378-Response-by-IHPN
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Verbatim wording from the response “It is clear from the CQC’s end of programme report that more work needs to be done to formalise the arrangements some independent providers have in place to deal with deteriorating patients and we have strongly encouraged all providers to have formal Service Level Agreements in place with neighbouring healthcare providers able to provide higher acuity care in the event of a patient’s health deteriorating unexpectedly. However, we are confident that the overall picture for the sector is good. IHPN members already have clear processes in place to manage deterioration and, where necessary, to arrange the transfer of patients to higher acuity settings.” Source location 2018-0378-Response-by-IHPN
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Verbatim wording from the response “The CQC’s State of care in independent acute hospitals published in April 2018 did cite examples of inconsistent monitoring of risks and examples where effective escalation did not occur within providers. In order to address this and other quality related findings, IHPN began a learning programme with the CQC to ensure that their view of what makes for outstanding care in the Safe domain is fully understood throughout the sector so that best practice can be adopted across the board.” Source location 2018-0378-Response-by-IHPN
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Verbatim wording from the response “It is clear from the CQC’s end of programme report that more work needs to be done to formalise the arrangements some independent providers have in place to deal with deteriorating patients and we have strongly encouraged all providers to have formal Service Level Agreements in place with neighbouring healthcare providers able to provide higher acuity care in the event of a patient’s health deteriorating unexpectedly. However, we are confident that the overall picture for the sector is good. IHPN members already have clear processes in place to manage deterioration and, where necessary, to arrange the transfer of patients to higher acuity settings.” Source location 2018-0378-Response-by-IHPN
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that patient transfers are particularly associated with hospitals lacking intensive-care facilities, and national guidance does not require on-site intensive care.
Verbatim wording from the response “We are not aware of any evidence to suggest that transfers of patients are particularly associated with providers who do not have intensive care facilities, such as NHS community and district general hospitals, mental health inpatient units and some independent sector hospitals. The NICE guidelines on patient transfers do not suggest that patients should only be treated where there are” Source location 2018-0378-Response-by-IHPN
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Verbatim wording from the response “Inter-hospital transfers are a well embedded mechanism to ensure that patients are treated in the most appropriate place should unanticipated complications arise. These transfers take place between providers of all types – from NHS providers to other NHS providers, from independent providers to independent providers, and from independent providers to NHS providers and vice versa.” Source location 2018-0378-Response-by-IHPN
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS hospitals are not the sole appropriate destination for deteriorating patients; some independent hospitals provide higher-acuity care and receive emergency transfers.
Verbatim wording from the response “Some independent sector providers do also have higher acuity facilities including intensive care and high dependency units. It is not the case that NHS providers are the sole option when patients need to be transferred to a different setting from an independent provider and some independent hospitals receive more emergency transfers than they transfer out.” Source location 2018-0378-Response-by-IHPN
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Multi-skilled independent-sector nurses are trained and assessed to identify complications and care for acutely ill patients; their broad competencies are considered a strength.
Verbatim wording from the response ““RAMSAY, the same as most other independent health care providers, cares for patients who are admitted for varying elective surgical procedures. These procedures may be in different craft groups and one of the best practice elements the independent sector can demonstrate is the care provided by trained multi-skilled staff. These staff are skilled in caring for a variety of patients with a variety of conditions and surgical procedures. They develop skills in identifying post-operative complications and are trained in caring for the acutely ill patient; and gain competence (which is tested and assessed) in delivering care in many settings and for many patients with differing problems.”” Source location 2018-0378-Response-by-IHPN
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations