Geoffrey Hoad

Regulation 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION  28  REPORT TO PREVENT DEATHS 

THIS REPORT IS  BEING SENT TO: 
Chief Executive 
East of England Ambulance Service NHS Trust 
Whiting Way 
Melbourn 
Cambridgeshire 
SG86EN 

1  CORONER 

I am  JACQUELINE LAKEJacqueline LAKE,  HM  Senior Coroner for the coroner area of 
NORFOLKNorfolk 

2  CORONER'S LEGAL POWERS 

I make this report under paragraph  7,  Schedule 5,  of the Coroners and  Justice Act 2009 and 
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and  INQUEST 

On  17 August 2022  I commenced an  investigation into the death of Geoffrey Douglas HOAD 
aged 85.  The investigation concluded at the end of the  inquest on  07  September 2023. 

The medical cause of death was: 

1 a) 
1 b) 
1c) 
2) 

Sub Acute Myocardial  Infarction 
Coronary Artery Atherosclerosis 

Hospital Admission for Post Operative lieus 

The conclusion of the inquest was: 
Mr Hoad underwent an  appropriate,  elective medical procedure on  3 August 2022, following 
which a paralytic ileus was diagnosed.  Mr Hoad's condition fluctuated  and did not respond to 
conservative management. The decision was made to transfer Mr Hoad to  Norfolk and 
Norwich University Hospital at approximately 18.00 on  6 August 2022 and an  ambulance 
called. The ambulance arrived at 08.26 hours on  7 August 2022.  Mr Hoad's condition 
continued to fluctuate. At 18.50 Mr Hoad rapidly deteriorated and  he died at 23.45 hours. 

4  CIRCUMSTANCES OF THE DEATH 

On  3 August 2022,  Mr Hoad underwent a total  hip replacement at The Spire Hospital.  On  5 
August 2022,  Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise 
with gradually deteriorating renal function.  On  6 August 2022,  Mr Hoad's transfer to  Norfolk 
and  Norwich University Hospital was agreed  due to possible bowel  obstruction,  possible 
pulmonary infection and  deteriorating renal function. 

Ambulance service was called at 18:16 hours and again at 23.45. On  7 August 2022, the 
ambulance service was called  again at 07.38 hours.  The ambulance was on  scene at 08:26 
hours. 

Mr Hoad was transported to  Norfolk and  Norwich University Hospital. At 11.30 am  ECG was 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021 

 undertaken which showed signs of cardiac ischaemia.  The evidence does not reveal  whether 
this ECG was reviewed.  The cardiac ischaemia was not noted and  acted  upon at this time.  By 
18.52 Mr Hoad  had clinically deteriorated with  continued  low blood  pressure and increased 
oxygen  requirements.  A repeat ECT showed  ongoing ischaemia which was recognised and  Mr 
Hoad was taken to Critical Care Complex at 20.18 hours with  a diagnosis of myocardial 
infarction.  Despite treatment,  Mr Hoad continued to deteriorate and  he died later that day on  7 
August 2022. 

5  CORONER'S CONCERNS 

During the course of the investigation my inquiries revealed  matters giving  rise to concern.  In 
my opinion there is a risk that future deaths could  occur unless action  is taken.  In the 
circumstances it is my statutory duty to report to you. 

The MATIERS OF CONCERN are as follows: 

1.  The ambulance service was called  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  6th  and ih August 
2022 and with  regard to the number of ambulances waiting at Hospitals in  the  region 
to hand  over patients and as to the significant pressure the  healthcare system was 
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,  including by way of training,  recruitment, 
working with  other ambulance services to develop a shared  plan for these 
circumstances and  also by way of collaboration with  local acute and  mental  health 
hospitals in the area to  look at ways to attempt to  alleviate the difficulties experienced. 
8.  Despite the steps being taken  by the EEAST, considerable delays in  attending to calls 

continue. 

6  ACTION SHOULD BE TAKEN 

In  my opinion action should  be taken to prevent future deaths and  I believe your organisation 
has the  power to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by November 06,  2023.  I,  the coroner,  may extend the  period. 

Your response  must contain details of action taken  or proposed to be taken,  setting out the 
timetable for action.  Otherwise, you  must explain why no action  is proposed. 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021 

 8  COPIES and  PUBLICATION 

I have sent a copy of my report to the Chief Coroner and  to the following  Interested Persons: 

Spire Norwich Hospital/Spire Healthcare Limited 
Norfolk and  Norwich University Hospitals NHS Foundation Trust 

I have also sent it to: 

Department of Health 
CQC 
HSIB 
Healthwatch 
NHS England & NHS Improvement who may find  it useful or of interest. 

I am  also under a duty to  send a copy of your response to the  Chief Coroner and all  interested 
persons who in  my opinion should  receive it. 

I may also send a copy of your response to any person who I believe may find  it useful or of 
interest. 

The Chief Coroner may publish either or both in a complete or redacted  or summary form.  He 
may send a copy of this report to any person who he believes may find  it useful or of interest. 

You  may make representations to me,  the coroner,  at the time of your response about the 
release or the  publication of your response by the  Chief Coroner. 

9 

Dated:  13/09/2023

s j~  
Jacqueline LAKE 
Senior Coroner for Norfolk 
County Hall 
Martineau Lane 
Norwich 
NR12DH 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021

Regulation 28:  REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form  is to be  used after an  inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS  REPORT IS  BEING SENT TO: 
Spire Norwich Hospital/Spire Healthcare Limited 

1  CORONER 

I am JACQUELINE LAKEJacqueline LAKE,  HM  Senior Coroner for the coroner area of 
NORFOLKNorfolk 

2  CORONER'S LEGAL POWERS 

I make this report under paragraph  7,  Schedule 5,  of the Coroners and Justice Act 2009 and 
regulations 28 and 29 of the  Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and  INQUEST 

On  17 August 2022 I commenced an  investigation into the death of Geoffrey Douglas HOAD 
aged 85.  The investigation concluded at the end of the  inquest on  07 September 2023. 

The medical cause of death was: 

1a) 
1 b) 
1c) 
2) 

Sub Acute Myocardial  Infarction 
Coronary Artery Atherosclerosis 

Hospital Admission for Post Operative lleus 

The conclusion of the inquest was: 
Mr Hoad  underwent an  appropriate,  elective medical procedure on 3 August 2022, following 
which a paralytic ileus was diagnosed. Mr Hoad's condition fluctuated  and  did not respond to 
conservative management. The decision was made to transfer Mr Hoad to  Norfolk and 
Norwich  University Hospital at approximately 18.00 on  6 August 2022 and an  ambulance 
called. The ambulance arrived  at 08.26 hours on  7 August 2022.  Mr Hoad's condition 
continued to fluctuate. At 18.50 Mr Hoad  rapidly deteriorated and  he died at 23.45 hours. 

4  CIRCUMSTANCES OF THE DEATH 

On  3 August 2022,  Mr Hoad  underwent a total  hip replacement at The Spire Hospital.  On  5 
August 2022,  Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise 
with gradually deteriorating renal  function.  On  6 August 2022,  Mr Hoad's transfer to Norfolk 
and  Norwich University Hospital was agreed due to possible bowel  obstruction,  possible 
pulmonary infection and deteriorating renal function. 

Ambulance service was called  at 18:16 hours and again at 23.45. On 7 August 2022, the 
ambulance service was called  again at 07.38 hours.  The ambulance was on  scene at 0826 
hours. 

Mr Hoad was transported to Norfolk and  Norwich University Hospital. At 11.30 am  ECG was 
undertaken which showed signs of cardiac ischaemia. The evidence does not reveal  whether 
this ECG was reviewed.  The cardiac ischaemia was not noted and acted  upon at this time.  By 
18.52 Mr Hoad  had clinically deteriorated with continued  low blood  pressure and increased 
oxygen  requirements.  A repeat ECT showed ongoing  ischaemia which was recognised,  and 
Mr Hoad was taken to Critical Care Complex at 20.18 hours with a diagnosis of myocardial 
infarction.  Despite treatment,  Mr Hoad continued to deteriorate, and  he died  later that day on  7 
August 2022. 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021 

 
 5  CORONER'S CONCERNS 

During the course of the  investigation my inquiries revealed  matters giving  rise to concern.  In 
my opinion there is a risk that future deaths could occur unless action  is taken.  In the 
circumstances it is my statutory duty to report to you. 

The MATIERS OF CONCERN are as follows: 

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  6th  and  th 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. 

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 

lnterfacility 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. 

6  ACTION SHOULD BE  TAKEN 

In  my opinion action should be taken to prevent future deaths and  I believe your organisation 
has the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by November 06,  2023.  I,  the coroner,  may extend the  period. 

Your response must contain  details of action taken or proposed to be taken,  setting out the 
timetable for action.  Otherwise, you  must explain why no action  is proposed. 

8  COPIES and  PUBLICATION 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021 

 I have sent a copy of my report to the  Chief Coroner and to the following  Interested Persons: 

East of England Ambulance Service NHS Trust 
Norfolk and  Norwich University Hospitals NHS Foundation Trust 

I have also sent it to: 

Department of Health 
CQC 
HSIB 
Healthwatch 
NHS England & NHS Improvement, who may find  it useful or of interest. 

I am also under a duty to  send  a copy of your response to the Chief Coroner and all  interested 
persons who in  my opinion should  receive it. 

I may also send  a copy of your response to any person who I believe may find  it useful or of 
interest. 

The Chief Coroner may publish either or both in  a complete or redacted  or summary form.  He 
may send  a copy of this report to  any person who he  believes may find  it useful or of interest. 

You  may make representations to  me,  the coroner,  at the time of your response about the 
release or the  publication of your response by the  Chief Coroner. 

9 

Dated:  13/09/2023 

sJ kµ_ 
Jacqueline LAKE 
Senior Coroner for Norfolk 
County Hall 
Martineau  Lane 
Norwich 
NR12DH 

Regulation  28 - After Inquest 
Document Template Updated 30/07/2021

From Helen Whately MP  
Minister of State for Care  

39 Victoria Street 
London 
SW1H 0EU 

2 May 2024 

Jacqueline F Lake 
Senior Coroner 
County Hall 
Martineau Lane 
Norwich 
N21 2DH 

Dear Mrs Lake, 

Thank you for your letter of 13 September 2023 to the Secretary of State for Health and Social 
Care Victoria Atkins, about the death of Geoffrey Douglas Hoad. I am replying as Minister with 
responsibility  for  Urgent and Emergency  Care.  Please accept  my  sincere  apologies for the 
delay in responding to this matter. I would like to assure you that the department is mindful of 
the  statutory  responsibilities  in  relation  to  prevention  of  future  deaths  reports  and  we  are 
prioritising responses as a matter of urgency.  

Firstly,  I  would  like to say  how  deeply  sorry  I  was  to read  the  circumstances  of  Mr  Hoad’s 
death and I offer my sincere condolences to his family.  I am grateful to you for bringing these 
matters to my attention.   

Your  report  raised  concerns  about  the  response  time  performance  of  East  of  England 
Ambulance  Service  NHS  Trust  (EEAST).  I  note  that  you  have  raised  these  concerns  with 
EEAST and Norfolk  and Norwich University  Hospitals  NHS  Foundation  Trust  who  are best 
placed to respond on the specific action being taken locally to support reduced ambulance 
response times. 

As the Minister responsible for urgent and emergency case services, I recognise the significant 
pressure  the  urgent  and  emergency  care  system  is  facing.  That  is  why  we  published  our 
‘Delivery  plan  for  recovering  urgent  and  emergency  care  services’  which  aims  to  deliver 
sustained  improvements  in  waiting  times,  including  to  reduce  Category  2  response  times 
(including for serious conditions such as heart attacks and strokes) to 30 minutes on average 
this year.  The plan is available at: 
https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-
recovering-urgent-and-emergency-care-services.pdf  

Your  report  highlights  that  EEAST  were  under  high  demand  at  the  time  of  the  incident.  A 
primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received 
£200 million of additional funding in 2023/24 to expand capacity and improve response times, 
and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of 
new ambulances and specialist mental health vehicles. With more ambulances on the road, 
patients will receive the treatment they need more swiftly.     

I recognise that ambulance trusts work within a health and care system and issues such as 
delayed patient handovers to hospitals can impact on capacity and response times. That is 

1 

 
 
 
 
 
 
 
 
  
 
 
 
  
   
  
   
 why  a  key  part  of the  delivery  plan  is  about  improving  patient  flow  and bed  capacity  within 
hospitals.  We  achieved  our  2023/24  ambition  of  delivering  5,000  more  staffed,  permanent 
hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, 
and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of 
scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are 
now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over 
two years to support the NHS and local authorities to ensure timely and effective discharge 
from hospital. These measures are helping improve patient flow through hospitals, reducing 
delays in patient handovers so ambulances can swiftly get back on the roads.     

At a national level, we have seen significant improvements in performance this year compared 
to last year. This year, average Category 2 ambulance response times (including for serious 
conditions such as heart attacks and strokes) were over 13 minutes faster compared to last 
year,  a  reduction  of  over  27%.  EEAST  average  Category  2  response  times  were  over  23 
minutes  faster  this  year  compared  to  last  year,  a  34%  reduction.  In  March  2024,  average 
patient  handover  times  in  the  EEAST  region  were  30  minutes  and  12  seconds,  and 
improvement of over 5 minutes from the previous month (information on ambulance handover 
times has been published since October 2023). In March 2024, average handover times in the 
EEAST region were 30 minutes 12 seconds, an improvement of almost 6 minutes from the 
previous month (information on ambulance handover times has been published since October 
2023). However, I recognise there is still more to do to reduce response times further, and the 
Government will continue to work with NHS England to achieve this.  

Thank you once again for bringing these concerns to my attention. 

Yours,  

HELEN WHATELY

INHS|

East of England

Ambulance Service
NHS Trust

HM Coroner Jacqueline Lake East of England Ambulance Service NHS Trust

Senior Coroner for Norfolk Whiting Way
By email Melbourn
Cambridgeshire
SG8 6NA
23 October 2023
Dear Ms Lake,

| am writing further to the inquest into the death of Geoffrey Hoad, which concluded on 7
September 2023. Following which you made a Regulation 28 Preventing Future Death Report
and this is the Trusts’ response to that report.

| understand that you heard evidence from (EEE, AOC Patient Safety Manager, during
the inquest in relation to the actions the Trust is taking to respond to Category 2 and 3 calls and
that you have acknowledged that a range of actions are being taken on both local and national
levels in relation to response times (as this is not an issue specific to this Trust) however you have
stated that despite the steps being taken, considerable delays in attending to calls continue.

The Trust has a range of specific actions in place to improve response times to patients which
include:

- Additional recruitment with the aim for there to be over 300 more frontline clinicians in place
by March 2024. Year on year we have increased patient facing hours by around 9% in
Norfolk and Waveney.

- Additional recruitment of clinicians within our control environment, allowing for greater
volumes of clinical triage to improve patient safety and to transfer patients to alternative
services where appropriate. This is supported by the establishment of an Unscheduled
Care Coordination Hub within Norfolk where we are working with the Integrated Care
Board, the 111 provider and community services to increase referrals of appropriate
patients to alternative services and to provide remote support to crews on scene. As a
result of these actions our rate of conveyance to hospital in Norfolk and Waveney is one
of the lowest in the Trust.

- The implementation of our Operational Performance and Improvement Plan (OPIP) which
is our plan to improve our own efficiency as an organisation and to maximise ambulance
availability, | attach a presentation on this with this letter to provide an update on this work.

Meeting the C2 response time has been a challenge for all ambulance services. Modelling by
NHS England (NHSE) demonstrates there is a strong relationship between hospital handover
delays and the ambulance C2 performance. NHSE’s regression model indicated that based on
previous performance, in order to reach an average response time of 30 minutes for C2 patients,

éWeAreEEASTIX

a maximum of 1,500 lost hours per week should not be exceeded (see graph below). Equally if
more than 1,500 hours are lost per week, the C2 response time is unachievable.

The Regional NHSE oversight meetings have been formed to support this important maximum
standard. Currently levels exceed this significantly and in Q1 weekly lost hours exceeded 2,700
hours per week.

Regional - Nov 22 onwards Rre=o9521

02:52:48

02:24:00

00:28:48 oo

« 200 3000 40c 000

20 700 8000

Hour

to handover

EEAST are a member of the Front Door Group looking to improve arrival to handover times. This
is chaired by the Deputy Director for Intensive Support from the NHSE/I team. We have shared
good practice from West Suffolk and Colchester Hospitals within the group, which is attended by
all Acutes in the area. EEAST have approached each Acute to review the current process and
suggested changes to allow quicker offloads.

EEAST has also been involved in an ‘Improvement Week’ which ran between the 9th and 13!"
October 2023 in Norfolk and Waveney. The clinical teams have been working alongside
crews, dispatchers, and call handlers to better understand the issues behind delays for patients
and helping identify ways to resolve them.

There is some indication that these actions are working, with C2 response times having reduced
by 29 minutes (39%) this September compared to last and C3 response times having reduced by
1 hour and 20 minutes (37%). However we recognise that further improvement is still required,
hence our continued focus on the range of actions identified above.

| hope this letter is helpful in setting out the steps we are taking to improve response times for our
communities, please do not hesitate to contact me should you require any further information.

Yours sincerely,

Chief Executive

nhs.uk

#WeAreEEASTW

6 November 2023 

HM Senior Coroner for Norfolk 
County Hall 
Norwich 
NR1 2DH 

Dear Madam 

3 Dorset Rise 
London 
EC4Y 8EN       

www.spirehealthcare.com 

I write to provide a response to the PFD issued on 7 September 2023 to Spire Healthcare Ltd 

Introduction  

1.  On 17th August 2022 HM Coroner opened an investigation into the death of Geoffrey Douglas 

Hoad, aged 85. The investigation concluded at the end of the inquest on 07 September 2023. 

The  medical  cause  of  death  was:  1a  Sub  Acute  Myocardial  Infarction  1b  Coronary  Artery 

Atherosclerosis 2 Hospital Admission for Psot Operative Ileus. The narrative conclusion is as set 

out in the Record of Inquest. 

2.  During the course of the investigation matters arose regarding the transfer of Mr Hoad from 

Spire Hospital to the Norfolk and Norwich University Hospital and, in particular, the significant 

delay  in  the  arrival  of  the  ambulance  to  facilitate  the  transfer  (the  first  call  being  made  at 

18:16hrs on 6 August 2022 and ambulance not arriving until 08:26 hours on 7 August 2022). The 

delay was as a result of resource issues at the East of England Ambulance Service NHS Trust 

(there was a very high call demand on the night of 6-7 August 2022). Although the delay was 

not found to be causative of Mr Hoad’s death, HM Coroner has expressed concerns that there 

is a risk of future deaths occurring in similar circumstances. She has therefore issued reports 

pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 

and  29  of  the  Coroners  (Investigation)  Regulations 2013  to:  to  Spire  Norwich  Hospital/Spire  

Healthcare Ltd, East of England Ambulance Service and the Secretary of State for Health 

3.  Paragraphs  1-8  of  section  5  of  the  Regulation  28  report  that  is  addressed  to  Spire  Hospital 

Norwich / Spire Healthcare summarise the facts. Paragraphs 9 to 12 are the specific matters of 

concern, as set out below; 

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

 
 
 
 
    
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 “9. Spire Norwich hospital does not deal with multidisciplinary and emergency treatment at its hospital and 

transfer 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  EEAST  to  look  at  a  pathway  in 

respect of Interhospital transfers. The evidence of EEAST was that this pathway was not expected to reduce 

delays in interhospital transfers 

12. This concern was raised at previous inquests”  

4.  These concerns are individually addressed below.  

General information: Spire Norwich Hospital (SNH) 

5.  SNH has: 

a. 

 60 beds, including 2 enhanced care beds and 4 operating theatres. 

b.  2 resident  doctors providing 24/7 on-site  cover. Consultant Anaesthetist  on-call cover is 

provided 24/7 by the Norwich Anaesthetist Group and East Coast Anaesthetic services. 

6. 

In the period 01.10.21 to 02.10.23 SNH had a total of 15,163 inpatient and day case admissions, of 

which  approximately  15%  were  NHS  patients.        It  is  important  to  note  that  (i)  NHS  patients 

undergoing procedures at SNH have access to the same levels of assessment, care and management 

as private patients and (ii) by accepting NHS patients, SNH is in effect helping to relieve NHS waiting 

lists/waiting times.   

7.  During these periods, 0.2% of patients in 2021-2022 and 0.1% of patients in 2022-2023 required 

transfer out from SNH to the NHS.  Transfers out are undertaken when there is a need for higher 

acuity care than SNH is able to provide (for example ITU care). 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 3 Dorset Rise 
London 
EC4Y 8EN       

www.spirehealthcare.com 

Response to Coroner’s concerns / Action taken  

9. Spire Norwich hospital does not deal with multidisciplinary and emergency treatment at its hospital 
and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich 
University Hospital 

General information  

8.  SNH is registered as a level 1 hospital with no on–site level 2/3 (HDU/ITU) provision.  

9.  A comprehensive pre-operative assessment (POA) is fundamental to high quality, safe practice, 

ensuring that the patient is as fit as possible for the surgery and anaesthetic.   

10. Spire Healthcare’s Adult Pre-operative Assessment Policy is based on recommendations from 

the  NHS  for  Innovation  and  Improvement,  NHS  Modernisation  Agency,  Royal  College  of 

Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) and 

sets out the requirements for comprehensive pre-operative assessments.  

11. Spire Healthcare’s Elective Adult Surgical Admission Guidance for level 1 (Enhanced Care Service 

Provision)  outlines  guidance  for  criteria  for  admission  in  hospitals  providing  level  1  care. 

Standards and levels of Adult Critical Care are aligned to Levels of Adult Intensive Care (second 

edition,  Intensive  Care  Society  UK)  consensus  statement  2021.  This  document  provides 

guidance on the adult elective surgical admission criteria used to assess a patient’s suitability 

for  surgical  admission,  including  cardiac  intervention  and  radiological  intervention  under 

general anaesthesia at a Spire Hospital with Level 1 care facilities.  

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

 
 
 
 
    
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 12. The  ASA  (American  Society of  Anaesthesiologists, 2014,  Amended Dec  2020)  Physical  Status 

Classification  System 

is  used 

to  assess 

fitness  before 

surgery  https://www. 

https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system  

13. SNH admits patients who are classified as ASA I – ASAIII 

14. Although SNH is registered as a level 1 hospital: 

a. 

 It can also provide (i) enhanced care for patients requiring more detailed observations 

than level 0 (ward) or (ii) or step-down care from Level 2-3 care. 

b. 

Importantly, in an emergency situation, SNH has the necessary equipment and access 

to relevant clinical expertise to stabilise and manage a patient who is acutely unwell, 

pending transfer to a higher-acuity facility.  

15. In circumstances where such a transfer is necessary, SNH has a service level agreement in place 

with the Norfolk and Norwich University Hospital for escalation of care to level 2/3 (HDU/ITU).  

This  agreement  sets  out  how  such  transfers  should  be  effected,  to  ensure  that  they  are  as 

efficient as possible,  

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

 
 
 
 
 
 
 
 
 
 
 
 
 3 Dorset Rise 
London 
EC4Y 8EN       

www.spirehealthcare.com 

in  the  interests  of  the  individual  patient  concerned,  and  our  respective  workforces.  This  is 

effective from June 2021 to June 2024, and it is envisaged that it will continue as is beyond that 

date. This arrangement is not unique to Spire, and both independent sector and NHS providers 

(such  as  smaller  general  hospitals)  are  required,  under  CQC  regulations,  to  have  similar 

arrangements in place.  

Action 1 
Complete audit of Spire Norwich Hospital compliance with Elective Adult Surgical Admission Guidance- 

level 1- enhanced care service provision. Audit to focus on patients assessed as ASA III (patients with 

severe systemic disease) 

16. The  audit  period  was  September  2022  to  September  2023.  It  comprised  a  medical  records 

review  of  10  randomly  selected  patients,  assessed  as  ASA  III,  and  was  conducted  to  assess 

compliance  with  the  defined  surgical  admission  criteria  outlined  the  Elective  Surgical 

Admissions Guidance mentioned above at para 11. The Audit results were: 

•  100% compliance with defined surgical admission criteria outlined in the Guidance. 

•  100%  compliance  with  patients  assessed  as  ASA  III  receiving  a  pre-operative  face  to  face 

assessment with a Consultant Anaesthetist. 

Action 2 

Review of all transfers of care from SNH to Norfolk and Norwich Hospital in the period October 

2021 to October 2023. 

17. In  the  12-month  period  October  2021  to  October  2022  SNH  had  a  total  of  7349 

inpatient and day case admissions, of which 16 patients’ care was transferred from 

SNH to the Norfolk and Norwich University hospital. This means that 0.2% of total 

inpatient and day case admissions required transfer of care. 

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

 
 
 
 
    
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 18. In the period October 2022 to October 2023 SNH had a total of 7814 inpatient and 

day  case  admissions,  of  which  11  patients’  care  was  transferred  from  SNH  to  the 

Norfolk and Norwich University hospital. This means that 0.1 % of total inpatient and 

day case admissions required transfer of care. 

19. All transfers of care are reported and investigated. No investigation found that the 

rationale 

for  transfer  of  care  was 

inappropriate.  No 

investigation  made 

recommendations that the rationale for transfer of care should be reviewed with the 

Consultant surgeon, Consultant Anaesthetist, Resident Doctors or Nursing team.  

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 

20. We  do  appreciate  the  pressures  on  EEAST,  which  have  existed  for  some  time  and 

continue to exist.  However, there is an important clinical benefit to private elective 

care  continuing  notwithstanding  these  pressures.  In  the  very  small  percentage  of 

cases  where  a  clinical  situation  occurs  at  SNH  that  warrants  a  patient  transfer  to 

higher acuity, such as critical care, it is entirely right that there is a need for EEAST’s 

services to support the transfer out and the continuance of that elective care. 

21. It  is  very  important  to  stress  that  all  patients  are  entitled  to  access  NHS  services, 

including access to NHS emergency ambulance services where clinically indicated, and 

regardless of how the need for that care arose, or where that patient is coming from.  

Private hospitals are part of the system of local healthcare and, far from increasing 

the burden on NHS providers, the reality is that private hospitals help to reduce that 

burden.  They take patients who would otherwise be on an NHS waiting list and, as 

set out in paragraph 6 above, they also treat NHS funded patients.   

22. The above obligations are rooted in the NHS Constitution for England, updated 17 

August 2023, which establishes the principles and values of the NHS in England. It sets 

out rights to which patients, public and staff are entitled, and pledges which the NHS 

is committed to achieve, together with responsibilities, which the public, patients and 

staff owe to one another to ensure that the NHS operates fairly and effectively.  

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

 
 
 
 
 
 
   
 
 
 3 Dorset Rise 
London 
EC4Y 8EN       

www.spirehealthcare.com 

23. The  Secretary  of  State  for  Health,  all  NHS  bodies,  private  and  voluntary  sector 

providers supplying NHS services, and local authorities in the exercise of their public 

health  functions  are  required  by  law  to  take  account  of  this  Constitution  in  their 

decisions and actions. The NHS constitution sets out seven key principles that guide 

the NHS in all it does. Principles 1, 2 and 5 are considered relevant when considering 

both  NHS  and  private  patient  access  to  NHS  Emergency  ambulances  when  an 

interfacility transfer is required: 

Principle  1.  The  NHS  provides  a 

comprehensive 

service,  available 

to  all.                                                                        

It is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, 

gender reassignment, pregnancy and maternity or marital or civil partnership status. The service 

is designed to improve, prevent, diagnose and treat both physical and mental health problems 

with equal regard. It has a duty to each and every individual that it serves and must respect their 

human rights. 

Principle 2.    Access to NHS services is based on clinical need, not an individual’s ability to pay. 

Principle 5.  The NHS works across organisational boundaries. 

It works in partnership with other organisations in the interest of patients, local communities and 

the  wider  population.  The  NHS  is  an  integrated  system  of  organisations  and  services  bound 

together  by  the  principles  and  values  reflected  in  the  Constitution.  The  NHS  is  committed  to 

working jointly with other local authority services, other public sector organisations and a wide 

range of private and voluntary sector organisations to provide and deliver improvements in health 

and wellbeing.  

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

 
 
 
 
    
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 24. Spire Healthcare is acutely aware of the demands placed on NHS ambulance services 

and the resulting delays in ambulance response times.  

25. SNH has completed a risk assessment in respect of ambulance transfer delays and this 

is recorded as the highest risk on the hospital risk register. 

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.  

27. In  2022,  SNH  contacted  2  local  CQC  registered  private  ambulance  providers  to 

consider  their  ability  to  support  interfacility  transfers  from  SNH.  Both  providers 

advised that they were subcontracted to support EEAST and therefore did not have 

the capacity to enter into a contract to provide a transfer service for SNH.  

28. Nonetheless, Spire is continuing to actively explore the possibility of making use of 

alternative providers of private ambulance services; at this point some potential new 

options  are  being  evaluated,  which  were  not  available  at  the  time  of  the  inquest.  

These will, of course,  still need careful consideration as to how  they sit within the 

emergency  response  timeframes  and  systems  receiving  these  patients  at  the 

destination facilities. 

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 EEAST to look at a 
pathway in respect of Interhospital transfers. The evidence of EEAST was that this pathway was not 
expected to reduce delays in interhospital transfers 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 Dorset Rise 
London 
EC4Y 8EN       

www.spirehealthcare.com 

29. The Inter Facility Tranfer 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: 

-  Acute Hospital Collaborative 

- 

James Paget University Hospital 

-  Norfolk and Norwich University Hospital 

-  Queen Elizabeth Hospital  

- 

- 

East of England Ambulance Service 

Spire Healthcare 

-  Adult Critical Care Transfer Service (ACCTS) 

30. It should be noted that EEAST’s PFD witness at the inquest (Head of Patient Safety) 

was not a member of the Interfacility Transfer Group (IFTG) until 02.10.23. 

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: 

a. 

Improving the quality of inter facility transfers for patients by risk stratification 

and  communication  between  organisations.    This  is  intended  to  standardise 

practice by:  

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

 
 
 
 
    
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • Adopting a consistent approach to identify patients requiring hospital escorts.  

•  Providing  clarity  on  the  level  of  expertise  and  training  required  for  hospital 

escorts.  

•  Promoting  criteria-based  decision  making  whilst  ensuring  clinical  judgement 

takes priority.  

b.  There  is  also  the  potential  to  increase  effective  utilisation  of  the  ambulance 

service provision by:  

• Appropriate use of paramedic/non paramedic crews.  

• Reduce requesting unnecessary blue light transfers.  

• Provision of hospital escorts with the relevant knowledge and skills to care for 

the patient during transfer (therefore no requirement for a paramedic crew).  

• Identifying low risk patients safe to use friends/relatives to provide transport.  

• Promote the appropriate use of ACCTS 

32. Whilst  it  is  noted  that  it  is  not  the  sole  purpose  of  the  IFTG  to  reduce  delays  in 

interfacility transfers, by improving the quality of interfacility transfers for patients by 

risk  stratification  and  communication  between  organisations  along  with  improving 

effective  utilisation  of  the  ambulance  service  it  is  expected  that  there  will  be  an 

improvement in interfacility transfer times. 

12. This concern was raised at previous inquests  

33. SNH  took  specific  action  following  the  concerns  raised  at  previous  inquests.  In 

particular,  it  joined  the  IFTG  and  has  been  working  closely  with  members  of  that 

group, including the Norfolk and Norwich Hospital. It was therefore a surprise to hear 

EEAST’s evidence on the IFTG at the inquest. As set out above, Spire Healthcare and 

SNH take the  issue of inter facility transfer extremely seriously and it continues to 

strive to mitigate the risks associated with the same. 

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

 
 
 
 
 
 
 
 
 
 
 
 
 3 Dorset Rise 
London 
EC4Y 8EN   

www.spirehealthcare.com 

34. It  is  hoped  that  the  information  set  out  above  provides  assurance  to  HM  Senior

Coroner that Spire Healthcare is taking appropriate steps to try and ensure that, on

the rare occasions that patients need to be transferred to higher acuity facilities, this

is  done  in  a  timely  and  safe  manner,  without  placing  undue  burdens  on  a  service

which is acknowledged to be experiencing severe capacity pressures.  Spire continues

to work closely  with  the  Ambulance  Service  and  local  NHS  Trusts  on  ways to  ease

delays for patients receiving care, recognizing that this is a challenge for the entire

local healthcare system.

Yours faithfully 

Group Clinical Director, Spire Healthcare 

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