Phoenix Hospital Group Limited

Health and care · Independent healthcare provider

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First report 4 Mar 2021•Latest report 4 Mar 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Phoenix Hospital Group Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Paula Anne SPEIRS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Paula Anne Speirs died following the ingestion of non-prescribed benzodiazepines before a planned procedure at Weymouth Street Hospital. The procedure was cancelled because staff considered her intoxicated, but she was allowed to sleep in a room without formal observations or specific monitoring instructions. The concerns included inadequate monitoring of an intoxicated patient and a lack of instructions to nursing staff on avoiding positional asphyxia.

    Read the report on judiciary.uk

    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 Phoenix Hospital Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide nurses with instructions on avoiding positional asphyxia

    Wider context from the report

    “1. However, in spite of her intoxication at 7am (from what was at the time an unknown substance, initially presumed to be alcohol), no formal observations were ordered or undertaken. Her room was easily accessible, but nobody was specifically tasked with monitoring her. No instructions were given as to how frequently she should be checked, or what that checking should involve. 2. The nurses looking after Ms Speirs were not given any instructions on how to avoid positional asphyxia. When I asked them about this at inquest, they explained that they had not previously heard of positional asphyxia. I have encountered positional asphyxia most frequently in a custodial setting. Detainees in police cells are now subject to very clearly laid down procedures that attempt to reduce the risk of positional asphyxia and to reduce drink and drug related deaths. It seems to me an omission that there is not a similar regime in a hospital, where one would expect the medical care to be of a higher standard. ”
    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 Phoenix Hospital Group Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement specified monitoring of an intoxicated patient

    Wider context from the report

    “1. However, in spite of her intoxication at 7am (from what was at the time an unknown substance, initially presumed to be alcohol), no formal observations were ordered or undertaken. Her room was easily accessible, but nobody was specifically tasked with monitoring her. No instructions were given as to how frequently she should be checked, or what that checking should involve. 2. The nurses looking after Ms Speirs were not given any instructions on how to avoid positional asphyxia. When I asked them about this at inquest, they explained that they had not previously heard of positional asphyxia. I have encountered positional asphyxia most frequently in a custodial setting. Detainees in police cells are now subject to very clearly laid down procedures that attempt to reduce the risk of positional asphyxia and to reduce drink and drug related deaths. It seems to me an omission that there is not a similar regime in a hospital, where one would expect the medical care to be of a higher standard. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026