Paula Speirs

Ms ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

30 April 2021  

Dear Ms Hassell  

Prevention of future deaths report following the inquest into the death of Paula Anne SPEIRS (died 28 August 
2020)  

I refer to the above Prevention of Future Death Report. 

We were greatly saddened by the death of Ms Speirs following her respiratory arrest and transfer out from The 
Weymouth Street Hospital (‘The Weymouth’) on 25 August 2020. I can confirm that this matter has been 
discussed with the Care Quality Commission (CQC) and we have provided full details of our actions taken 
including supporting documentation to the CQC. We would like to again offer our sincerest condolences to the 
family for their loss. 

As set out in our Serious Incident Review (SIR) and as noted at the Inquest, Ms Speirs arrived at The Weymouth 
at approximately 7.05 am on 25 August 2020 for an elective surgical procedure. The decision was taken not to 
proceed with her surgery by 
, Consultant 
Anaesthetist. No formal admission pathway was initiated for Ms Speirs however Ms Speirs was shown to an 
individual ward room (room 301). A full set of observations were carried out in the room by the HCA and 
reported to the registered nurse. Ms Speirs requested to freshen up in the room’s en-suite facilities and was 
subsequently assessed by 

, Consultant Plastic Surgeon and Dr 

 and the nurses.     

, Dr 

Whilst Ms Speirs was awaiting collection by her husband she rested with the bedroom door left open, allowing 
her to be observed by our Ward Manager, 

 (a registered nurse of 36 years’ experience) and 

 (a registered nurse of 20 years’ experience).  

 was the registered nurse on duty for 

the third floor on the day in question. 
her sleeping position.    

 maintained visual observations, including a regular review of 

Although she was drowsy, Ms Speirs roused easily to voice and responded to questions (indicating Glasgow 
Coma Scale of 13-14). She moved herself into the recovery position when requested by staff and was also 
observed by the Resident Medical Officer (RMO).   

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
  
  
 
 
  
  Ms Speirs was in the hospital under visual observations for approximately four hours before she was found 
unresponsive. 
resuscitation. Appropriate resuscitation efforts were made by Weymouth Street Hospital staff after Ms Speirs 
suffered a respiratory and cardiac arrest. Ms Speirs subsequently required to be transferred out to University 
College London Hospital (UCLH) for further treatment and monitoring.  

 immediately initiated the pathway for cardiopulmonary 

In your Prevention of Future Death Report, you highlighted the following points and I will address each in turn in 
this letter: -  

1.  The fact that no formal observations were ordered or undertaken, including ensuring that a nominated 
individual was tasked with monitoring her. No instruction was given on how frequent she should be 
checked or the nature of that review;  

2.  The nurses looking after Ms Speirs were not given any instructions on how to avoid positional asphyxia 
and when the Coroner asked regarding this risk, the nurses had not previously heard of positional 
asphyxia.  

Response regarding formal observations for patients  

Ms Speirs’ attendance to The Weymouth was exceptional in that she did not initiate any of the hospital’s formal 
admission pathways. Indeed, strictly she was not admitted, merely allowed to use a room until collected. Ms 
Speirs was planned to be admitted as a surgical patient, however as the decision to cancel the procedure was 
made soon after arrival formal documentation was not commenced as it normally would be.   

, 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. 

It is recognised that The Weymouth’s processes and protocols should be reviewed and addressed in the light of 
this incident and the Coroner’s findings.  

I have broken down the steps taken as follows: -  

1. Audit  

I enclose a copy of an audit of the records of formal observations of patients at The Weymouth between January 
and March 2021. As you will see, this identifies that of 100 patients, 95 were the subject to formal and regular 
assessment. Of the 5 remaining, 3 patients initiated our outpatient pathway as outpatient ‘Walk in Walk out’ 
patients who do not require formal observation. One patient was a sleep study which followed a specific 
pathway, and the final exception was a patient whose procedure was cancelled. This patient’s procedure was 
cancelled on the day due to having a fever identified in reception.   

During the Covid pandemic, The Weymouth has operated a ‘Green Pathway’ ensuring that all patients isolate as 
per NICE guidelines, have a Covid-19 PCR swab performed 72 hours prior to admission and have a temperature 
reading taken on admission which must be within normal ranges. This ensures safety of the patients undergoing 
anaesthetics, other patients within the hospital and The Weymouth team.   

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
  
  
  
 As the above patient presented with a fever, she failed the Covid screening even though she appeared well, and 
the operation was subsequently cancelled. This patient was using NHS transport to get to and from the hospital. 
For the safety of staff and patients, the decision was made to isolate the patient and therefore move them to an 
individual ward room. The patient had to wait 2 hours for NHS transport to arrive. In this time the patient was 
offered food and their temperature was rechecked. No formal observations were conducted or documented. 
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.   

Please refer to the audit report attached for a full summary of conclusions.   

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.  

2. Policies and Protocols   

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.  In addition, this has now been amended to make it clear that patients are deemed ‘admitted’ from 
point of signature on the registration form in reception even if never having formal admittance documentation 
completed. This ensures that all staff are aware of their duty of care towards all patients whilst present at The 
Weymouth. This policy also states that patients that appear visibly intoxicated cannot proceed with their 
planned procedure.   

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.   

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.  

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
 
 
 
 
 
 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. 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).  

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.   

In addition, and for ease of reference, I enclose copies of our Major Haemorrhage Policy, Management of a 
Deteriorating Patient and Resuscitation Policy. We include these documents as they have had recent revisions 
and show our robust safety approach to emergency procedures.  

3. Training  

I enclose records of mandatory eLearning competencies completed by Weymouth Ward staff.  This record 
details that compliance is regularly monitored by the Ward Manager, Human Resources, the Clinical Governance 
team and the Director of Operations. Any staff that have expired mandatory training are given time within their 
shift to complete it and given opportunities to request additional training if required. This record shows the 
extensive training and learning available to clinical staff via our online learning portal ‘MyCloud’.  

Moreover, I enclose a copy of further completed eLearning competencies via the online portal e-LfH, which has 
been made available to Phoenix Hospital Group by the NHS during the pandemic and going forward. These 
competencies are additional to the mandatory training and staff have been encouraged to take advantage of the 
access to eLearning via this platform.    

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.   

In summary, all our staff are trained, given revision and tested in line with established hospital, including NHS, 
practice. 

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
 
  
  
  
 
 
  
 4. Review and Communication  

I enclose a copy of the minutes of the Serious Incident Review Group lead by the Chairman of our Clinical 
Governance Committee, Medical Director, Responsible Officer and other Senior clinicians which reviewed the 
Coroner’s findings.  

I enclose minutes of the meeting of the Weymouth’s Clinical Governance Management Meeting, Ward Nurses 
meeting and Clinical governance meeting with Weymouth Managers and their deputies, at which the relevant 
issues were highlighted and addressed.  

Further, I attach minutes of the meeting with the staff nurses involved, and reflection and debrief, following the 
recommendations from the Prevention of Future Deaths report.  

I also enclose the minutes of the ward meeting, confirming the discussion of Resuscitation, ILS, training and the 
identification and management of the deteriorating patient.  

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.  

It should be noted that under our Practising Privileges agreement, responsibility for the care of the patient rests 
with the admitting consultant. I have met along with our Responsible Officer and Chairman of our Clinical  
Governance Committee with 
in light of the Coroner’s comments.  I enclose a copy of the letters to 

 to review the learning and reflection by the Consultants 

 and Dr 

 and Dr 

. 

Response regarding Positional asphyxia  

It was stated at the Inquest that none of the 4 witnesses was aware of the condition ‘positional asphyxia’.    

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. 

It is our understanding that positional asphyxia is defined as occurring when a person is placed in a posture that 
prevents or impedes the mechanism of normal breathing. If the person cannot escape from the position, it can 
result in asphyxia. Typically a restraint would be the cause of the subject being unable to escape from the 
position e.g. pressure is applied to the back of the person held in the facedown prone position, or pressure is 
applied restricting the shoulder girdle or accessory muscles of respiration.  There is no physical restraint, 
restrictive interventions or rapid tranquilisation used at the Weymouth Street Hospital.  

In any event, The Resuscitation Council (UK), National Patient Safety Agency (NSPA), and NICE guidance suggests 
that even in any setting where restrictive interventions (rapid tranquilisation, restraint or seclusion) are used, 
there should be immediate access to staff trained in ILS and to appropriate ILS medication and equipment. 
Further to this, those who deliver or are involved in rapid tranquilisation, physical restraint and seclusion are 
trained in ILS.   

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
 
 
  
 
 
 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.  

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.   

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

In support of and as evidence of the above I enclose a selection of documents as evidence:- 

1.  Please see enclosed a statement from Dr 

, Consultant Anaesthetist with significant 

experience and a note of a conversation with 
Skills department at Middlesex University, regarding the term positional asphyxia.    

, Senior Lecturer and Head of the Clinical 

2.  We also have enclosed an SOP from Kent Police highlighting the relevance of positional asphyxia in a 

custodial environment.  

3.  We wrote to the Resuscitation Council and the Royal College of Nursing to seek further guidance on the 
training in and the use of the term positional asphyxia and have included copies of our letters and the 
responses received.  

As you will see, the Resuscitation Council UK advise that positional asphyxia is not a term that the Immediate 
Life Support (ILS) course would routinely use as it is not relevant to the clinical scenarios on the course.  

The Resuscitation Council UK further advise that the Immediate Life Support (ILS) Course is primarily aimed at 
healthcare professionals who may act as the first responder in an emergency and teaches the skills to manage a 
deteriorating patient and initiate life support to patients who suffer a cardiac arrest. ILS candidates are 
healthcare professionals from a variety of backgrounds, and it is not possible to include all potential clinical 
scenarios. However, airway management is a core element of the course and causes of airway obstruction, 
recognition, and treatment of airway obstruction are all covered in the course manual and e-learning materials. 
Airway management skills are also assessed during hands on skill teaching sessions and throughout the scenario 
sessions.  As confirmed above, all clinical staff at The Weymouth are trained and attend annual refresher 
courses in ILS.  

A response was also received by the Royal College of Nursing advising that the Resuscitation Council UK are best 
placed to advise in this area as they are national experts and they set policy. 

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford 

  
 
  
  
 
 
 
 
 
 
 
 
 Further learning   

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.  

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.  

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.   

Further action and next steps  

I enclose a timeline setting out those steps still to be taken.  

I enclose for ease of reference a schedule of supporting documents along with the relevant supporting 
documents.   

Summary 

Ms Speirs was an extremely sad and unusual death. Due to the unusual nature of her presentation, Ms Speirs 
did not initiate any of The Weymouth’s formal admission pathways. Phoenix Hospital Group and particularly 
Weymouth Hospital staff have been greatly impacted by the events that occurred. The Weymouth has reviewed 
and revised many of our policies and procedures as well as implemented new ones where needed.  Significant 
learning and reflection has occurred. However, within our reviews, we have also found many of our policies and 
procedures are robust and appropriate. Our audit and the enclosures demonstrate we do undertake 
observations and provide a safe environment. As a result, we believe we meet and in many instances now 
exceed the requirements set by policy in other NHS and private hospitals.  

We will be sending a copy of this letter to our relevant contact at the Care Quality Commission. 

We are committed to ensuring The Weymouth Street Hospital is the safest possible environment for patients 
and would be pleased to receive feedback or comments on any of the steps or points highlighted in this letter.  

With best wishes.  

Yours Sincerely   

Chief Executive Officer  
Phoenix Hospital Group  

Phoenix Hospital Group Ltd| Company registration number 04634173 | Registered office 9 Harley Street, London W1G 9QY 
Weymouth Street Hospital | 9 Harley Street | 25 Harley Street | Phoenix Hospital Chelmsford