Faizan Nazar

MB BS  FRCPsych 

Consultant Psychiatrist 

GMC:4146829 

BMI The Cavell Hospital 
Cavell  Drive 
Uplands Park Road 
Enfield EN2  7PR 

The Priory 
Grovelands House 
The Bourne 
London  N 14 6RA 

BMI The Kings  Oak Hospital 
Chase  Farm  North Side 
The Ridgeway 
London  EN2 85D 

To, 
MD Fleming 

HM Senior Coroner for 
West Yorkshire Western Coroner Area 

HM Coroner's Court 

Cater Building 

1 Cater Street 

Bradford 
BDl SAS 

Dear Sir, 

Re:  Regulation 28 report dated the 4th  of April 

Since  HM  Coroner' s Inquest on  29 March 2022 touching the death of Faizan  Nazar, I have reflected 
at length on this case and how I can  try to limit the possibilities of patient's failing to make follow-up 

appointments as  advised in the future. 

A. CURRENT PRACTICE  FOR  PATIENTS WANTING TO  MAKE APPOINTMENTS 

New patients:  new patients either contact the hospital directly or my secretary to request an 
appointment. They are often provided names by their insurance company or through the hospital 
website or their GPs. 

Follow up appointments: when I offer follow-up appointments, I will request the patient to make an 
appointment within a certain time frame for example after 6 to 8 weeks or 3 months. When patients 

are seen face to face it is  easier for them to make the appointment through the outpatient reception 
soon when leaving the initial appointment. 

For virtual appointments I ask the patients to make an  appointment again  by either contacting my 

secretary or the hospital directly to book it, based on  availability or their convenience, as  patients 

have other commitments such as  work or family. 

To  prevent any delay or for that matter if patients wish to be seen  sooner, I always ask patients to 

contact me via  my secretary in  case things are not going well or they need further advice. I do get 

contacted regularly by this route and  respond typically within 24 hours 

1 

 The hospital would not be aware of the request made to the patient to arrange a follow up. Once an 

appointment is  made the patient will get a letter to confirm the appointment including the date and 

time. 

Currently I do not have a system in  place to remind patients that they have not made an 

appointment. Often patients will make an  appointment later than the scheduled time . 

B.  NEW SYSTEM  FOR  REMINDING  PATIENTS ABOUT THE  NEED  FOR  MAKING FOLLOW  UP 
APPOINTMENTS 

From this week onwards if following a clinic appointment, a patient requires a follow up I will 
immediately email my secretary of the planned follow-up for the patient and  advise her to remind 

the patient 2 weeks before the scheduled time to make an  appointment if they have not already 
done so.  If they do not respond  I will inform the GP that they are no longer attending my clinic and 

inviting them to contact me again should they wish to re-refer the patient. 

If you require any further details or clarification, please do not hesitate to contact me and  I shall 

endeavour to assist in  any way I can. 

Yours  sincerely 

2

Se

Spire Healthcare

3 Dorset Rise

London
EC4Y 8EN
HM Senior Coroner for West Yorkshire (West) fF
HM Coroner's Court
Cater Building www.spirehealthcare.com
1 Cater Street
Bradford
BD1 5AS
16/06/2022
Dear Sir,

RE: Faizan Nazir
Response to Regulation 28 Report behalf of Spire Harpenden Hospital

| write to you today in response to a Regulation 28 Report dated 4 April 2022, addressed to Spire
Harpenden Hospital.

As you are aware:-

e Spire Harpenden was not afforded Interested Person status at the inquest;

e Spire Harpenden was never contacted by your office about the tragic death of Mr Nazir and
did not attend the inquest;

e Atno point was Spire Harpenden asked to provide any evidence or information to the Court
prior to the conclusion of the inquest.

Notwithstanding the same, following evidence heard by the Consultant Psychiatrist treating Mr Nazir
on a private basis via Spire Harpenden Hospital, you issued a Regulation 28 Report in which you
expressed concern in the following terms:-

“[Mr Nazir’s Consultant Psychiatrist] told me that it was not customary at Spire Harpenden Hospital to
forward written reminders of a patient’s forthcoming appointments. In my opinion there is a risk that
future deaths could occur unless action is taken.”

We would like to make it clear from the outset that as a leading healthcare provider we take the
issuing of any Regulation 28 Report very seriously. A Regulation 28 Report, once issued, is not limited
in scope to the Coronial process. We understand that the Coroner also provided a copy of the
Regulation 28 Report to the COC as our Regulator, who requested further information, which we can
confirm has already been provided separately. A Regulation 28 Report also prompts internal action
as part of our own clinical governance and as part of ongoing consideration as to how systems can be

Spire Healthcare Group Plc is registered in England
and Wales. Registered No. 09084066
Registered Office: 3 Dorset Rise, London, EC4Y 8EN

improved for the benefit and safety of our patients. Further, as an organisation we recognise that the
tragic loss of Mr Nazir coupled with concern expressed by the Court as to the systems in place at the
time may have compounded the family’s distress. We would therefore wish to pass on our sincere
condolences to the family and greatly regret that we were not provided with an opportunity to
address these concerns from the outset at the inquest itself when we could have provided clarity for
you and the family.

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 HE siaic 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).

It is of serious concern to us that a Regulation 28 Report was issued without being properly grounded
in the evidence provided to the Court. | have taken legal advice about the matter, and | understand
the position to be as follows:

e Under Regulation 28(3) of the Coroners (Investigation) Regulations 2013 it is a pre-condition
to issuing a Regulation 28 Report that all the documents, evidence and information that the
Coroner considers to be relevant to the investigation must be considered. Whilst we recognise
that it is for the Coroner to consider which evidence or information is relevant to the scope of
the inquest, in circumstances where there was concern as to the system but no current
evidence as to the system in place at an organisational level, we consider that it would have
been appropriate to seek such evidence prior to conclusion of the inquest and in any event
prior to the implementation of statutory powers.

e Weare concerned that there was a lack of proper regard as to the Chief Coroner’s Guidance
in relation to the issuing of a Regulation 28 Report. For the avoidance of doubt, unrelated to
these events, Eh as moved his private practice and no longer practises at the Spire
Harpenden Hospital.

e Paragraph 28 of the Guidance states that Coroners should be careful, particularly when
reporting about something specific, to base their report on clear evidence at the inquest and
to express clearly and simply what that information or evidence is. Again, this did not occur
as we consider that the Regulation 28 Report does not accurately reflect the evidence that

was in fact given by

We therefore consider that we ought to have been offered the opportunity to make representations
and/or provide evidence prior to your implementation of your statutory powers. We consider it
unlikely that a Regulation 28 Report would have been issued in the terms expressed had we been
invited to make representations or provide evidence to the Court from the outset.

Notwithstanding the above, we do recognise that there was evidence provided as to whether there
was any system in place to remind a privately paying patient of a clinician’s recommendation to
arrange a follow-up appointment (the same being a factually different premise to that set out within
the Regulation 28 Notice). We recognise that, without further explanation from Spire, the same may
give rise to concern. In the circumstances, and coupled with the need to address the concern actually

Spire Healthcare Group Plc is registered in England
and Wales. Registered No. 09084066
Registered Office: 3 Dorset Rise, London, EC4Y 8EN

expressed in the Regulation 28 Report, we confirm that the current systems in place at Spire
Harpenden Hospital with regards to arranging appointments are as follows:

a) Process for making an appointment with a consultant

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 a i: 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. Patients can also make appointments by directly contacting the
hospital, but in Mr Nazir’s case all his appointments were made via nse cretary.

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

Once an appointment has been confirmed on the hospital management system as above, a
patient will receive a confirmation of appointment via letter and a text message is sent to a
patient 48 hours in advance of the date itself to remind them of the upcoming appointment. The
purpose of sending a reminder in these circumstances is to avoid missed appointments that have
already been booked by the patient which was not the case in this situation as Spire was not made
aware by the consultant of his request to Mr Nazir to book an appointment. We can confirm that
no issues have therefore been identified with Spire’s system, and it is noted that Mr Nazir did not
miss any appointments that he had in fact booked with [i

c) Process for sending reminders to make an appointment that has been recommended by the
Consultant but not then booked by the patient.

It is our understanding that, notwithstanding the concern as expressed in the Regulation 28
Report, it is the above scenario that was in fact considered during the course of the inquest. Dr
| RS recommended a follow-up appointment in 6-8 weeks. Following his consultation in
May 2021, EM did not then take any steps to ascertain whether Mr Nazir wished to book
a further appointment nor was any reminder to book a further appointment sent to Mr Nazir. No
further appointment between | Mr Nazir was arranged after May 2021. Therefore
this tragic case does not relate to a situation where a patient had booked an appointment with
Spire and had not attended that appointment, but rather it relates to a situation where Spire was
not made aware, by the consultant, of his request to a patient to arrange a follow up
appointment. The examination therefore of any system (if appropriate) would properly be that
which concerned the consultants’ arrangements for following up patients who failed to make
contact despite advice, and notifying the patients’ GP if they failed to respond.

Spire Healthcare Group Plc is registered in England
and Wales. Registered No. 09084066
Registered Office: 3 Dorset Rise, London, EC4Y 8EN

If a follow-up appointment is recommended by a clinician, our expectation as an organisation is
that the same is clearly communicated to the patient (either verbally or in a clinic letter or both)
in line with a doctor’s professional obligations. What action is then taken to follow through with
that recommendation would, of course, rest with the individual patient, supported by guidance
from his consultant and GP.

We trust that any concerns have now been allayed and any misunderstandings now rectified.

In the circumstances, we would invite the Court to consider whether the Regulation 28 Report ought
to be withdrawn given that the same was issued on an incorrect evidential basis as set out above.
Insofar as we are aware, there is nothing within the Coroners and Justice Act 2009 or the Coroner’s
(Investigation) Regulations 2013 that directly prohibits a Regulation 28 Report being rescinded and
such action would appear to be appropriate if the factual basis upon which the same was issued is
incorrect.

Yours faithfully,
a

Group Medical Director

Spire Healthcare Group Plc is registered in England
and Wales, Registered No. 09084066
Registered Office: 3 Dorset Rise, London, EC4Y 8EN