PFD report

Paula Anne SPEIRS · Prevention of Future Deaths report

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Issued 4 Mar 2021•Inner North London

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
15

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 raised2

  1. Failure to provide nurses with instructions on avoiding positional asphyxia
    Part of recurring concern: Inadequate controls for positional asphyxia during patient handling and care
  2. Failure to implement specified monitoring of an intoxicated patient
    Part of recurring concern: Unreliable patient observation arrangements
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.8

  1. Action

    Establish a suspected-intoxication policy covering identification, monitoring, clinical intervention, escalation, transfer, and safeguarding.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
  2. Action

    Re-audit formal observations quarterly to verify that the revised observation policy is followed for all patients.

    Stated by Phoenix Hospital GroupStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
  3. Action

    Train ward staff through simulation on revised observation, transfer, deteriorating-patient, resuscitation, massive-transfusion, and intoxication policies.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Training specifically on positional asphyxia was considered inappropriate because restrictive interventions are not used and the subject is outside accredited ILS training.

    Stated by Phoenix Hospital GroupNo action considered necessaryThe respondent said that no further action was needed.

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 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. ”

Is this part of a recurring concern?

Yes — Inadequate controls for positional asphyxia during patient handling and care.

Open source report

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

Open source report

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

Establish a suspected-intoxication policy covering identification, monitoring, clinical intervention, escalation, transfer, and safeguarding.

Verbatim wording from the response

“We have also established a policy for the management of a suspected intoxicated patient, a copy of which is attached. This policy gives guidance on the management of a patient who attends in a state that appears intoxicated, including suspected or known, accidental or intentional overdose or poisoning of a known or unknown substance. The protocol includes conducting a rapid bedside toxicology saliva screen to detect and confirm the presence of cannabis, cocaine, opiates, amphetamines, benzodiazepines, methamphetamines and alcohol. This policy ensures the early identification of a suspected intoxicated patient, appropriate escalation, ongoing monitoring, clinical intervention, and process for escalation to facilities beyond The Weymouth’s capabilities. The policy ensures holistic and thorough management and considers safeguarding.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 2021

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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

Re-audit formal observations quarterly to verify that the revised observation policy is followed for all patients.

Verbatim wording from the response

“It is our intention to re-audit on a quarterly basis to ensure our policy results in formal observations on all patients even if not having treatment.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 2021

Open published response

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

Train ward staff through simulation on revised observation, transfer, deteriorating-patient, resuscitation, massive-transfusion, and intoxication policies.

Verbatim wording from the response

“I also enclose copies of internal facilitator reports following Middlesex University simulation training in March 2021 as well as a report from internal simulation training conducted by the Clinical Governance and Risk Leads. During this training, ward staff received education on the revised Massive Transfusion Policy, Transfer Out Policy, Observation Policy, Deteriorating Patient and Resuscitation Policy and Suspected Intoxicated Patient Policy.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 2021

Open published response

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

Disseminate learning about positional asphyxia from the investigation to all clinical staff.

Verbatim wording from the response

“To acknowledge our newly acquired knowledge regarding ‘positional asphyxia’, the learnings from this investigation have been disseminated with all clinical staff.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 6 · response
Published 8 March 2021

Open published response

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

Implement four-hourly ward observations with defined documentation, escalation tools, and clinical responsibilities from admission to discharge.

Verbatim wording from the response

“I enclose a copy of the ward observations, reporting and escalation policy which now formally states that all surgical and medical patients within The Weymouth will be observed at no less than 4-hour intervals from admission to discharge. It clearly outlines the documents which are present in specific locations that can be initiated by staff, such as neurological observations charts and the UK NEWS2 Charts which were already in use. The observation policy details the expectations that all clinical staff are required to follow regarding observation documentation including clear responsibilities amongst clinical staff.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 2021

Open published response

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

Implement a consultant-completed care plan for non-surgical patients, cancellations, and medical admissions, specifying observation frequency and discharge arrangements.

Verbatim wording from the response

“I also enclose a formal care plan which has now been implemented and is to be in place for any non-surgical patient including cancellations of surgery or medical admissions. This is to be completed by the admitting Consultant. It clearly specifies the expectation from the Consultant on frequency of observation and a clear discharge pathway.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 2021

Open published response

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 education and ongoing simulation on the suspected-intoxication policy for Weymouth and Phoenix Hospital Group staff.

Verbatim wording from the response

“Education on this new policy, as well as ongoing simulations, has been undertaken for all Weymouth staff (and indeed all staff across Phoenix Hospital Group).”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 2021

Open published response

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

Require formal observations and documentation for all patients, including those not receiving treatment, throughout attendance.

Verbatim wording from the response

“The observation policy, in conjunction with the admission policy and departmental teaching, has modified operational procedures such that, moving forward, this patient would have had a full set of observations conducted and documented throughout their attendance at The Weymouth even though this does not occur routinely at other private or NHS hospitals. This information would then be passed on by the consultant to the patient’s GP for follow-up post-departure.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 2021

Open published response

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

Training specifically on positional asphyxia was considered inappropriate because restrictive interventions are not used and the subject is outside accredited ILS training.

Verbatim wording from the response

“The Weymouth is not a setting where restrictive interventions are used, nor are there any clinicians who deliver restrictive interventions so Weymouth staff, like other hospitals, do not actively train for it and it would be inappropriate to do so. All clinical staff are trained and attend annual refresher courses in ILS (Resus Council accredited) at Middlesex University covering all relevant aspects as determined by the professional trainers and the approved curriculum. Positional asphyxia is not included in any Resus Council accredited ILS training.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 6 · response
Published 8 March 2021

Open published response

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

Unfamiliarity with positional asphyxia was neither unusual nor criticism-worthy because the hospital does not use restraint, restrictive interventions or rapid tranquilisation.

Verbatim wording from the response

“Despite comprehensive investigation we have failed to identify that this term is used or taught in training or clinical practice in healthcare in the UK, with the exception of environments where physical restraint or rapid tranquilisation are employed e.g. in police custody/ cells or in a mental health facility. It is true the four witnesses were unaware of the term, but that is neither unusual nor a matter for criticism.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 5 · response
Published 8 March 2021

Open published response

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

Formal observations were conducted on arrival and staff maintained visual observations, disputing that the patient received no observations.

Verbatim wording from the response

“████████, who was the lead Consultant responsible for her care, and Dr ████████, as her anaesthetist, examined her in the patient room and both undertook a lengthy consultation. Upon arrival to her room, a set of formal observations were conducted and documented in the patient’s notes. The nurses and RMO maintained visual observations for the duration of Ms Speirs stay.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 2 · response
Published 8 March 2021

Open published response

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

Existing airway-management training and recovery-position skills were considered sufficient to address airway obstruction and patient positioning risks.

Verbatim wording from the response

“Positional asphyxia is simply not taught in the UK in an acute hospital setting. However, the knowledge and skills for management of the airway is taught, which includes appropriate use of the recovery position. It is important to note that Ms Speirs was placed in this position in line with Resuscitation Council guidelines. The knowledge and skills for management of the airway and positioning of a patient, is embedded in clinical care delivered at the Weymouth and throughout Phoenix Hospital Group.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 6 · response
Published 8 March 2021

Open published response

Other statements in published responses

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

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Communicate admitting consultants’ responsibility for patients, including during the pre-surgical period, through a formal consultant communication.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
  2. 2

    Update transfer procedures and mandate transfer to an appropriate setting for patients who may develop an unsafe airway.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
  3. 3

    Deliver further simulation training for staff unable to attend the previous session.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
  4. 4

    Conduct a final reflection and learning session covering the inquest, regulatory and coroner responses, and process improvements.

    Stated by Phoenix Hospital GroupStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
  5. 5

    Schedule a Managing a Deteriorating Patient workshop for all ward clinical staff.

    Stated by Phoenix Hospital GroupStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
  6. 6

    Revise admission procedures to require anaesthetist responses, define non-admission safety criteria, and deem patients admitted from registration.

    Stated by Phoenix Hospital GroupStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
  7. 7

    Highlight the Coroner’s concerns to nurses through regular weekly briefings.

    Stated by Phoenix Hospital GroupStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.

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

  1. 1

    Under practising-privileges agreements, responsibility for patient care rests with the admitting consultant.

    Stated by Phoenix Hospital GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Communicate admitting consultants’ responsibility for patients, including during the pre-surgical period, through a formal consultant communication.

Verbatim wording from the response

“Finally, I attach a copy of the Communication to all Consultants admitting patients to the Weymouth emphasising their responsibility for patients at the Weymouth including for the pre-surgical period.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 5 · response
Published 8 March 2021

Open published response

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

Update transfer procedures and mandate transfer to an appropriate setting for patients who may develop an unsafe airway.

Verbatim wording from the response

“The Transfer Out Policy, already comprehensive, has been further updated. A copy is attached. This policy gives guidance to Weymouth staff on ensuring that the patient who requires further support are transferred safely with minimal adverse events, in a timely manner by suitably trained staff to an appropriate facility. We now also mandate all patients who may develop an unsafe airway must be transferred to a more appropriate setting for their specific condition.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 2021

Open published response

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 further simulation training for staff unable to attend the previous session.

Verbatim wording from the response

“Further simulation training conducted by the Clinical Governance and Risk leads has been undertaken for staff that were unable to attend the previous session. The simulation outcome report is attached. In addition, we are currently scheduling a Managing a Deteriorating Patient workshop to be conducted by Middlesex University for all ward clinical staff to attend.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 7 · response
Published 8 March 2021

Open published response

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 final reflection and learning session covering the inquest, regulatory and coroner responses, and process improvements.

Verbatim wording from the response

“Additionally we will be undertaking a final reflection and learning session into the Inquest, the current response to the CQC and Coroner and any other process improvements, which I will lead as Chief Executive.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 7 · response
Published 8 March 2021

Open published response

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

Schedule a Managing a Deteriorating Patient workshop for all ward clinical staff.

Verbatim wording from the response

“Further simulation training conducted by the Clinical Governance and Risk leads has been undertaken for staff that were unable to attend the previous session. The simulation outcome report is attached. In addition, we are currently scheduling a Managing a Deteriorating Patient workshop to be conducted by Middlesex University for all ward clinical staff to attend.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 7 · response
Published 8 March 2021

Open published response

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

Revise admission procedures to require anaesthetist responses, define non-admission safety criteria, and deem patients admitted from registration.

Verbatim wording from the response

“I enclose a copy of a revised admission policy. The Weymouth has been unusual in having robust universal pre-assessment for many years; each patient undergoes formal assessment and the assessment is sent to the anaesthetist asking if further tests or interventions are required. The pre-assessment nurses are supervised by another consultant anaesthetist and follow a number of pre-set pathways for hypertension, diabetes etc that follow the latest national guidelines. In the light of this case we have now mandated that a formal response must be received from the anaesthetist even when no further pre-assessment intervention is required. It also sets out reasons for non-admission with a comprehensive list of conditions that are unable to be admitted due to safety.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 2021

Open published response

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

Highlight the Coroner’s concerns to nurses through regular weekly briefings.

Verbatim wording from the response

“Even though the nursing staff followed Resuscitation Council guidelines, we will also be highlighting the issues raised by the Coroner to our nurses through our regular weekly briefings.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 7 · response
Published 8 March 2021

Open published response

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

Under practising-privileges agreements, responsibility for patient care rests with the admitting consultant.

Verbatim wording from the response

“Finally, I attach a copy of the Communication to all Consultants admitting patients to the Weymouth emphasising their responsibility for patients at the Weymouth including for the pre-surgical period.”

Source location

2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 5 · response
Published 8 March 2021

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