13 Sep 2023 Geoffrey Douglas HOAD · Prevention of Future Deaths report Norfolk
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Concerns raised 4 Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment View source Continuing delays in ambulance attendance View source Delays in ambulance responses to calls View source Continuing delays in ambulance service attendance to calls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Geoffrey Douglas HOAD · 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
Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.
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× 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report “9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital.
10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.
11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers.
12. This concern has been raised at previous inquest.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in ambulance attendance
Wider context from the report “1. Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours.
2. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.
3. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.
4. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.
5. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.
6. Evidence was heard as to the very high call demand overnight on the 6th and 7th August 2022 and with regard to the significant pressure the healthcare system was and remains under.
7. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system.
8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance responses to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue . The Trust is of the view that only by reducing system pressures as a whole, including hospital handover delays and community services being able to deal with their patients, will pressure on the ambulance service be alleviated to enable them to respond effectively and in a timely manner to their patients . This is to a great extent outside the control of the regional EEAST.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Continuing delays in ambulance service attendance to calls
Wider context from the report “8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue .
” 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 Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “24. Spire Healthcare is acutely aware of the demands placed on NHS ambulance services and the resulting delays in ambulance response times.” Source location Response from Spire Healthcare
Open published response
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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 Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
Open published response
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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 Complete and register a group-wide risk assessment addressing ambulance transfer delays.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
Open published response
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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 Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
Verbatim wording from the response “31. Following the inquest into the death of Mr Hoad and the subsequent concerns raised by HM Coroner, SNH raised concerns to the chair of the Interfacility Transfer Group that EEAST’s PFD witness had stated in court that the work of the IFTG was not expected to reduce delays in interhospital transfers. The chair of the IFTG met with EEAST’s Head of Patient Safety and it was agreed that, as of 02.10.23, they (EEAST’s PFD witness at the inquest) would join the IFTG in order that they are fully aware of the purpose of the group and involved in all associated actions. The intended benefits of the IFTG are as follows:” Source location Response from Spire Healthcare
Open published response
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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 Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
Verbatim wording from the response “29. The Inter Facility Transfer Group (IFTG) led by NNUH was set up to facilitate the inter facility transfer of unplanned emergency patients in the local area. Its first meeting took place in June 2022. As at October 2023, the membership of the group comprises representatives from the following organisations:” Source location Response from Spire Healthcare
Open published response
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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 Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
Verbatim wording from the response “Action 2
Review of all transfers of care from SNH to Norfolk and Norwich Hospital in the period October 2021 to October 2023.” Source location Response from Spire Healthcare
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
Verbatim wording from the response “26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.” Source location Response from Spire Healthcare
Open published response
28 Jun 2023 Carol Ann Hatch · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 15 Continuing risk from clinical failings capable of contributing to avoidable death View source Insufficient competence of overnight clinical staff View source Delays in urgent diagnostic imaging for patients displaying septic shock symptoms View source Failure by the reviewing doctor to escalate patient deterioration View source Inaccurate clinical record keeping View source Failure to assure agency nurses’ competence, induction and handover View source Failure to identify and access out-of-hours radiographer support View source Failure to alert senior clinicians to unexpected patient deterioration View source Failure to report concerns about clinicians’ competence to regulatory bodies View source Delays in urgent blood sample delivery and reporting View source Reliance on agencies to assess the competence of supplied clinical staff View source Failure to reconcile clinical documentation with the patient’s observed condition View source Delays in transferring patients in pain to extended care or higher monitoring View source Failure to take clinical observations during a high-risk interval View source Failure to accurately perform and interpret clinical observations for escalation View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carol Ann Hatch · 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
Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her death.
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× 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Continuing risk from clinical failings capable of contributing to avoidable death
Wider context from the report “14. Evidence taken from a consultant surgeon at the Inquest indicated that the failings at Spire Hospital contributed (more than minimally) to the death of Mrs Hatch on 18 October. This view dovetails with the medical opinion obtained by Spire Healthcare Limited themselves to the effect that this death was “avoidable” .
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient competence of overnight clinical staff
Wider context from the report “12. Overall, the cluster of failings on 31 August/1 September brought into question the competence of the staff looking after Mrs Hatch on duty at the Spire Hospital that night . The Inquest was informed that such concerns had not been reported to the regulatory bodies of those involved, The RMO continues to practice at the Spire Hospital.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in urgent diagnostic imaging for patients displaying septic shock symptoms
Wider context from the report “8. When the surgeon sought an x ray at 8.35 am there was a delay until this took place at 10.09 am . There was a failure to appreciate the urgency of the situation in a patient who was displaying symptoms of septic shock.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure by the reviewing doctor to escalate patient deterioration
Wider context from the report “6. The RMO was called to review Mrs Hatch twice during the night but failed to appreciate the deterioration in her condition necessitated an escalation to the surgeon and/or anaesthetist .
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccurate clinical record keeping
Wider context from the report “5. The records kept were inaccurate ; for example, there was no record of oxygen being provided around 2 am .
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assure agency nurses’ competence, induction and handover
Wider context from the report “2. Mrs Hatch was cared for during the night by an agency nurse who had not worked at the hospital previously. No records were produced to the Inquest to demonstrate she was (a) competent (b) had an induction to the hospital or (c) received a handover at the start of the shift.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and access out-of-hours radiographer support
Wider context from the report “9. It was not readily apparent to some of those involved at that time that an out of hours radiographer could have been called in. This was a further missed opportunity to investigate her condition before it deteriorated.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to alert senior clinicians to unexpected patient deterioration
Wider context from the report “1. Mrs Hatch’s condition deteriorated markedly during the night of 31 August/1 September 2022 (some hours after surgery). Neither the surgeon nor the anaesthetist were alerted to this unexpected deterioration. The Surgeon only became aware of the position when he contacted the hospital and came in around 7 am.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report concerns about clinicians’ competence to regulatory bodies
Wider context from the report “12. Overall, the cluster of failings on 31 August/1 September brought into question the competence of the staff looking after Mrs Hatch on duty at the Spire Hospital that night. The Inquest was informed that such concerns had not been reported to the regulatory bodies of those involved , The RMO continues to practice at the Spire Hospital.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in urgent blood sample delivery and reporting
Wider context from the report “10. Blood samples taken at 8.02 am were not delivered to the laboratory until 9.06 am and then not reported on until 10.21 am as they had not been marked as ‘urgent’. This also reflects a failure to appreciate the gravity of the situation .
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on agencies to assess the competence of supplied clinical staff
Wider context from the report “13. The Inquest was informed that Spire Healthcare Limited rely on agencies who supply clinical staff to assess their competence (whilst retaining a power of veto over any individual put forward). Given the importance of having competent nurses and doctors on duty overnight further consideration should be given to the methods by which professional competence is assessed and staff from agencies are engaged.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile clinical documentation with the patient’s observed condition
Wider context from the report “11. The RMO was the senior doctor at the hospital overnight. The RMO recorded a note at 8.45 am “feeling much better now”. The Inquest noted a discrepancy between this comment and the fact that Mrs Hatch was deemed too unwell to be moved to the radiology department at 9.10am, some 25 minutes later.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients in pain to extended care or higher monitoring
Wider context from the report “7. When Mrs Hatch was observed to be in pain there was a delay in moving her to an extended care unit (“ECU”) bed or otherwise escalating the level of monitoring . This did not take place until 9.50 am .
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to take clinical observations during a high-risk interval
Wider context from the report “4. No observations whatsoever were taken in the period between 3 am and 6.25 am , despite the patient having been recorded as “crying in pain” around 10pm.
” 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 Spire Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately perform and interpret clinical observations for escalation
Wider context from the report “3. The nurse took observations at times during the night but either omitted some elements or misinterpreted the information with the result that the NEWS scores were inaccurately portrayed . This resulted in missed opportunities to escalate concerns to a doctor, more serious colleagues or the surgeon .
” 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 Book registered colleagues without current ILS training onto forthcoming ILS training.
Verbatim wording from the response “Current ILS compliance for registered colleagues at Spire Leeds is 77%, against the target of 90%. Colleagues who do not currently have ILS training are booked onto training in the near future. Sepsis training is part of ILS competency. We have 100% compliance in performing quarterly scenarios of which sepsis is included.” Source location Response from Spire Healthcare Limited
Open published response
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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 Provide deteriorating-patient training to agency staff through the supplier competency process.
Verbatim wording from the response “As part of the learning from this event, the team at Spire Leeds have shared and discussed the findings in the RCA with this nurse’s agency. The core supplier competency checklist includes requires that agency staff are competent in the management of the deteriorating patient. The new checklist must be signed by the candidate as well as the agency to ensure both are confirming the information is correct.” Source location Response from Spire Healthcare Limited
Open published response
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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 Deliver training to RMOs on recognising deteriorating patients and signs of gastric perforation.
Verbatim wording from the response “This matter was recognised in the RCA, has been discussed with the RMO and there is a plan in place for training to be delivered to RMOs on recognising signs of a deteriorating patient and recognising signs of gastric perforation. In addition, Spire has received confirmation that the RMO has undertaken a recent appraisal. We refer the Coroner to evidence file relating to the RMO which includes evidence of action taken in relation to this concern.” Source location Response from Spire Healthcare Limited
Open published response
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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 Provide NEWS refresher training to relevant colleagues and conduct regular audits of NEWS compliance.
Verbatim wording from the response “In addition to addressing NEWS training with agency staff, the hospital have ensured a NEWS update refresher has been provided to all relevant colleagues and have conducted regular audits to provide assurance in relation to compliance.” Source location Response from Spire Healthcare Limited
Open published response
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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 Introduce deteriorating-patient stickers for clinical use.
Verbatim wording from the response “ADDITIONAL ACTIONS EVIDENCE” Source location Response from Spire Healthcare Limited
Open published response
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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 Share and discuss RCA findings with the nursing agency and implement a competency checklist signed by agency staff and the supplier.
Verbatim wording from the response “As part of the learning from this event, the team at Spire Leeds have shared and discussed the findings in the RCA with this nurse’s agency. The core supplier competency checklist includes requires that agency staff are competent in the management of the deteriorating patient. The new checklist must be signed by the candidate as well as the agency to ensure both are confirming the information is correct.” Source location Response from Spire Healthcare Limited
Open published response
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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 Display NEWS 2 posters for staff reference.
Verbatim wording from the response “ADDITIONAL ACTIONS EVIDENCE” Source location Response from Spire Healthcare Limited
Open published response
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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 Agree in principle with Leeds Teaching Hospitals to support clinical competence maintenance.
Verbatim wording from the response “In addition, Spire Leeds has close links with Spire Manchester, who provide Level 3 (ICU) care and an agreement with Leeds NHS Hospitals where our colleagues can attend to maintain ongoing competence in specific areas, for example, arterial lines, inotropes, non-invasive ventilation, transfer training.” Source location Response from Spire Healthcare Limited
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The RMO’s agency was considered best placed to assess whether the incident was isolated or required wider performance action or GMC escalation.
Verbatim wording from the response “Evidence was heard at the inquest that consideration was given to referring the RMO to the GMC following this incident. The RMO’s skill set, and competency were discussed at a Scrutiny Panel on 17th February 2023 attended by hospital and senior clinical and medical management at Spire. It was concluded that the findings of the RCA and the known practice of the RMO did not meet the threshold for referral to the GMC. It was agreed that the hospital team would share the RCA with the RMO’s agency, which was completed on 16th March 2023. It was agreed that the RMO’s agency were best placed to assist us in understanding whether this was an isolated episode or not, whether there were any wider performance concerns that needed to be addressed or matters requiring escalation to the GMC.” Source location Response from Spire Healthcare Limited
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Referral of the RMO to the GMC was considered unnecessary because the RCA findings and known practice did not meet the referral threshold.
Verbatim wording from the response “Evidence was heard at the inquest that consideration was given to referring the RMO to the GMC following this incident. The RMO’s skill set, and competency were discussed at a Scrutiny Panel on 17th February 2023 attended by hospital and senior clinical and medical management at Spire. It was concluded that the findings of the RCA and the known practice of the RMO did not meet the threshold for referral to the GMC. It was agreed that the hospital team would share the RCA with the RMO’s agency, which was completed on 16th March 2023. It was agreed that the RMO’s agency were best placed to assist us in understanding whether this was an isolated episode or not, whether there were any wider performance concerns that needed to be addressed or matters requiring escalation to the GMC.” Source location Response from Spire Healthcare Limited
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations