PFD report

Faizan Qadeer Nazar · Prevention of Future Deaths report

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Issued 4 Apr 2022•West Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to provide patients with written reminders of forthcoming appointments
    Part of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Send appointment confirmation letters and 48-hour reminder text messages for appointments booked on the hospital management system.

    Stated by Spire Harpenden HospitalStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The Regulation 28 concern is factually incorrect because the evidence did not establish that Spire lacked customary written appointment reminders.

    Stated by Spire Harpenden HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide patients with written reminders of forthcoming appointments

Wider context from the report

“During the course of the inquest I heard evidence from Dr ████████, Faizan’s treating Consultant Psychiatrist who told me that it was not customary at Spire Harpenden Hospital to forward written reminders of a patients forthcoming appointments. ”

Is this part of a recurring concern?

Yes — Unreliable arrangement and communication of patient appointments and follow-up.

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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

Send appointment confirmation letters and 48-hour reminder text messages for appointments booked on the hospital management system.

Verbatim wording from the response

“b) Process for sending reminders of an appointment that has been made”

Source location

Response from Spire Healthcare
Page 3 · response
Published 26 April 2022

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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 Regulation 28 concern is factually incorrect because the evidence did not establish that Spire lacked customary written appointment reminders.

Verbatim wording from the response

“Having now had an opportunity to consider the recording of the evidence that was provided to the Court, we believe that the concern expressed in the Regulation 28 Report is factually incorrect. At no point during his evidence did ████████ state that it was not customary to forward written reminders of a patient’s forthcoming appointments. Had he stated as such, this would in any event have been incorrect (for the reasons we have set out below).”

Source location

Response from Spire Healthcare
Page 2 · response
Published 26 April 2022

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Follow-up arrangements for recommended but unbooked appointments rest with the individual clinician, patient, consultant and GP rather than Spire.

    Stated by Spire Harpenden HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Follow-up arrangements for recommended but unbooked appointments rest with the individual clinician, patient, consultant and GP rather than Spire.

Verbatim wording from the response

“As is industry standard, Consultants at Spire are not employed but practise on a self-employed basis, under practising privileges. Patients’ appointments are typically booked via a consultant’s private secretary. It is noted that Mr Nazir was able to effectively use this system and that he made appointments with ████████ via his secretary on more than one occasion. It should be noted that Spire is not responsible for the diaries of individual Consultants with practising privileges at the hospital. This responsibility lies with the individual clinician, and they make their own arrangements for diarising appointments with their secretary. Once a patient has decided they wish to book an appointment, the same is confirmed with the clinician and then entered onto the Hospital’s system.”

Source location

Response from Spire Healthcare
Page 3 · response
Published 26 April 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026