Julie Pytches

H.M Area Coroner 
Ms Sonia Hayes 
Seax House  
Victoria Road South Chelmsford  
Essex  
CM1 1QH 

Nuffield Health 
Epsom Gateway 
Ashley Avenue 
Epsom 
Surrey 
KT18 5AL 

Ref: 2026-0164 

                                                                                        6 May 2026 

Dear Ms Hayes,  

Regulation 28 Report - Response 

I write in response to your Regulation 28 Report dated 18 March 2026 issued following the Inquest 
into the sad death of Mrs Julie Anne Pytches. Please consider this letter as Nuffield Health’s formal 
response to the matters raised in the report. 

At the outset, I would like to extend our deepest sympathies and condolences to Mrs Pytches’ family 
for their loss. Our heartfelt sympathies go out to all those who have been affected by her death; we 
recognise that this has been an extremely challenging time for them. We have taken on board HM 
Coroner’s comments, and I would like to reiterate our commitment to addressing, as far as possible, 
any area for improvement identified through internal and coronial review of this case.  

Background   
Mrs Pytches had a history of back pain. She was first seen as an NHS patient in an outpatient clinic 
at The Holly Hospital (operated by Nuffield Health) on 20 March 2023. Subject to obtaining updated 
imaging, it was agreed she  would undergo L4/L5 spinal decompression and fusion. The consent 
form for surgery was signed at a follow up consultation on 13 July 2023, with possible risks and 
complications being discussed before signature.   

Following a pre-operative assessment on 02 October 2023, Mrs Pytches was admitted for surgery 
on the morning of 14 October 2023. She was assessed by the Anaesthetist, and it was noted that 
she  had  pre-operative  morbidities  (high  BMI,  high  blood  pressure,  diabetes)  and  deemed  ASA 
grade 3.  She was assessed as fit for surgery. 

At  approximately  08.30  Mrs  Pytches  was  taken  to  theatre,  anaesthetised  and  placed  in  the 
appropriate  prone  position.  The  first two hours of  surgery  went  without complication.  There  was 
then  a minor  endplate  bleed,  when  the  disc  material  was  removed,  which  was  repaired.  As  the 
operating Consultant was preparing to insert the cage into the disc space, Mrs Pytches suffered a 
drop  in  blood  pressure  and  a  cardiac  arrest.  The  Consultant  removed  the  external  metal  work, 
packed the surgical site and she was turned  onto her back (supine) in order that CPR could be 
commenced. A crash call was made.   

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 
 
 
 
 
 
 
 
 
       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Resuscitation commenced, as the Hospital Resus team responded to the crash call alongside two 
additional  Consultant  anaesthetists  from  adjoining  theatres.  Mrs  Pytches  received  resuscitation 
fluids,  blood and  standard  epinephrine.  The Hospital  made a 999 call, the first  ambulance crew 
arrived at 11.00, the second arrived at 11.23 and fitted a LUCAS machine to deliver automatic chest 
compressions.  Subsequently  the  HEMS  team  from  the  Air  Ambulance  arrived  at  11.49.  Mrs 
Pytches’  abdomen  started  to  distend,  and  the  attending  Consultant  considered  opening  the 
abdomen to locate the source of the bleed, however, it was deemed that this would be futile. Sadly, 
after 90 minutes of resuscitation, a decision was made to stop resuscitation at 12.14 hours.   

The initial Post-Mortem Report recorded the cause of death as:   
1a) Intra-abdominal haemorrhage of uncertain aetiology   
1b) Antecedent causes   
1c) Morbid conditions (if any) giving rise to the above cause stating the underlying condition 
last   
2) Spinal surgery (operated October 2023)  

Following  the  provision of  various  witness statements,  a supplemental Post-Mortem  Report  was 
prepared, which recorded the cause of death as:   

1a) Massive intra-abdominal haemorrhage   
1b) Spinal surgery (operated October 2023)   
1c) Morbid conditions (if any) giving rise to the above cause stating the underlying condition  
2) Other significant conditions contributing to death, but not related   

The Inquest was partially heard on 14 and 15 April 2025 before being adjourned.  The Inquest was 
re-convened on 27 – 30 October 2025.    

 At the Conclusion of the Inquest, HM Coroner recorded the medical cause of death as follows:   

1a Intra-abdominal Haemorrhage of Uncertain Aetiology   
1b Spinal surgery (operated October 2023)   

HM Coroner recorded a short narrative conclusion as follows: Misadventure secondary to spinal 
surgery.  

HM  Coroner  made findings  under  Regulation 28  and  a  Regulation  28  Report  to  Prevent  Future 
Deaths was issued on 18 March 2026. HM Coroner raised four matters of concern under Regulation 
28.  

HM  Coroner  specifically  noted that  the  Regulation  28  concerns did  not  contribute  to  this  patient 
death. 

Quality and safety are of paramount importance at Nuffield Health. We take any concerns about 
our systems and processes very seriously and will always work to learn from any incidents. The 
matters  raised  by  HM  Coroner  have  been  considered  and  discussed  by  our  Board  Quality  and 
Safety Committee and shared with the Trustees of the Charity as well as the Patient Safety Partner 
Team. 

Our responses to the matters raised are set out below.  

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 
 
 
 
 
 
 Matter of Concern 1 

An Anaesthetist who responded to an emergency crash call had limitations on his ability to 
participate in resuscitation. These limitations had been declared to his team on the day but 
had not been shared with the Hospital Management where he was participating in surgery. 
The  Hospital  Management  did  not  have  an  opportunity  to  consider  the  limitations  on  the 
Doctor’s  practice  as  a  part  of  a  risk  assessment  and  to  ensure  that  the  limitations  were 
acceptable  in  all  the  circumstances  and  that  any  potential  risks  mitigated.  There  is  no 
requirement  or  process  for  doctors  to  notify  their  limitations  to  the  private  hospital 
management.  

Nuffield Health’s Response:  

At the time of the Incident:  

•  When  Mrs  Pytches  went  into  arrest  she  was  attended  by  two  Consultant Anaesthetists,  the 
Consultant  Surgeon,  the  Operating  Department  Practitioner,  the  theatre  support  staff  and 
hospital resuscitation team.  

•  The  concern  related to a third  Consultant  anaesthetist  who  was requested to  assist  with the 
arrest and who was working in different operating theatre. He had informed his theatre team of 
limitations relating to musculo skeletal condition which meant that he was not physically able to 
assist with resuscitation. However, he had not followed due process by declaring this limitation 
to the hospital management team earlier.  

•  At the time of the incident (October 2023), it was an express requirement of the extant Practising 
Privileges Policy that the Consultant should notify the Hospital Director or Clinical Manager as 
soon as practicable of any health matters (including any mental health issues), which may affect 
their clinical practice and judgement or safety of patients and staff.  

•  This allows the hospital to assess patient risk, coordinate mitigation, and communicate promptly 
with  relevant  teams.  On  receipt  of  such  a  notification,  hospital  leadership  is  responsible  for 
ensuring timely dissemination of information across affected teams and for establishing clear 
leadership  of  actions  on  the  day,  including  consideration  of  case  prioritisation,  deferral, 
cancellation,  or  appropriate  alternative  cover  (where  clinically  appropriate  and  with  verified 
Practising Privileges). 

•  As  a  result  of  this  incident  the  Hospital  suspended  the  Consultant’s  Practising  Privileges. 
Following  a  period  of  reflection  and  a  full  explanation  from  the  Consultant  his  Practising 
Privileges were re-instated.  

Actions / Measures already in place across all Nuffield Health hospitals:  

• 

It is a requirement of the Nuffield’s Practising Privileges policy that all medical practitioners must 
notify  the  Hospital  Director  or  Medical Advisory  Committee  Chair  of  any  health  or  personal 
issues that may affect performance, judgement, or patient safety. This includes temporary or 
permanent changes impacting practice. 

•  Nuffield’s  Practising  Privileges  renewal  process  (updated  March  2026)  now  requires  explicit 
confirmation that Consultants have discussed workload, wellbeing, and full scope of practice 
during their most recent appraisal, and that their workload remains safe and sustainable. 

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 • 

In addition, Responsible Officer (RO)-to-RO information sharing processes support proactive 
communication of information of note where health matters may impact patient safety or lead 
to restrictions or changes in practice.  

•  General  Medical  Council  (GMC)  Good  Medical  Practice  (2024)  further  reinforces  the 
professional  duty  of  doctors  to  seek  advice  and  adjust  practice  when  health  conditions  or 
treatment may affect performance.  

•  Where a concern is identified - either self-declared or raised by another team member - this is 
acted  upon  immediately. A  proportionate  risk  assessment  is  undertaken,  and  the  matter  is 
escalated  to  the  appropriate  senior  clinician  or  manager  in  accordance  with  local  policy. 
Mitigating actions may include staff replacement, adjustment of roles, enhanced supervision, or 
delay or cancellation of the procedure where required to maintain safety. 

•  These arrangements, which are already in place, support a strong safety culture, encourage 
staff to speak up, and ensure that surgery only proceeds when it is safe to do so. The process 
is consistent with organisational policies on fitness to practice, escalation, and staff wellbeing, 
and reflects Nuffield Health's commitment to patient safety, effective teamwork, and regulatory 
compliance. 

Further actions across Nuffield Health:  

Although  it  is  an  express  requirement  of  Nuffield  Practising  Privileges  Policy  for  medical 
practitioners to share relevant health or personal issues, Nuffield are taking the following actions:  

• 

In order to further communicate and reinforce the above requirement, the Consultant induction, 
and Practising Privileges renewal checklists will be updated to explicitly include the obligation 
to notify hospital management of any temporary or permanent limitations to practice, including 
same-day changes, by the end of June 2026.  

•  Any  future  learning  arising  from  same-day  inability  to  perform  full  duties  will  continue  to  be 
reviewed through established governance processes, including escalation where relevant via 
Patient Safety Incident Reporting Framework reporting. 

Matter of Concern 2 

Mrs Pytches suffered a major haemorrhage whilst undergoing spinal surgery and there was 
confusion about the protocol and procedures at the hospital. Consultants with practising 
privileges  in  this  private  healthcare  organisation  were  not  all  aware  of  policies  and 
emergency procedures required and these are subject to local variation within the Group 
organisation across the country. Doctors may have practising privileges in more than one 
hospital that may cause confusion as to what is required in individual hospitals within the 
Group.  There  is  assurance  that  Consultants  are  required  to  acknowledge  they  have  read 
policies,  however  this  does  not  mean  this  local  variation  is  clear  particularly  for  a  less 
frequently occurring emergency life-threatening event.  

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 
 
 
 Nuffield Health’s Response:  

At the time of the Incident:  

•  At  the  time  of  the  incident  (October  2023),  the  Hospital  was  operating  under  the  Aspen 
Practising Privileges Policy. It was an express requirement of the Policy that a Consultant must 
comply  with  all  relevant  policies  and  procedures  applicable  to  their  clinical  practice  and 
governance. The Aspen Practising Privileges Policy explicitly stated that it was the responsibility 
of  medical  practitioner  to  ensure  they  are  aware  of  such  policies  and  procedures  and  any 
amendments or replacements thereto. 

Actions / Measures already in place across all Nuffield Health hospitals:  

• 

It  is  also  a  requirement  of  NH’s  Practising  Privileges  Policy  that  all  Consultants must at  all 
times comply with all of NH’s policies and procedures, at all of the hospitals where they hold 
Practising Privileges as made available and amended at any time by Nuffield. 

•  The Medical Director sent a letter to all Consultants with Practising Privileges in January 2024 
specifically reminding them of this requirement, emphasising the need for Consultants to have 
read  and  understood  the  policies  within  the  hospital  where  they  work  and  to  familiarise 
themselves with any Service Level Agreements in place between all of the hospitals at which 
they hold Practising Privileges  and the local NHS Trusts.  

•  Nuffield has implemented MyStaff, a centralised policy management system providing real-time 
access to Group-level and local policies via desktop and secure mobile application. We are the 
first independent provider to have done this. This ensures policies are more accessible at the 
point  of  care  and  that  users  are  alerted  when  documents  are  updated.  Phase  1  (launched 
November 2025) migrated all Group policies and associated documents to the platform. Phase 
2  (launched  April  2026)  introduced  analytics  to  monitor  readership  of  critical  policies, 
strengthening assurance and enabling targeted follow-up. All staff and Consultants have 24/7 
access to policies via the MyStaff app (on and off site). 

•  Emergency  reference  guides  are  consistently  available  across  all  departments  and  include 
guidance  for  cardiac  arrest  and  major  haemorrhage  in  line  with  Nuffield  Health  Policy  CL71 
Medical Emergencies and Resuscitation Council guidelines. The availability, accessibility and 
use of these guides are routinely reviewed and reinforced through regular emergency scenario 
training  and  simulations  to  ensure  staff  familiarity  and  effective  application  in  practice. 
Laminated emergency algorithms, including adult major haemorrhage pathways, are located on 
resuscitation trolleys and in key clinical areas.  

•  Major haemorrhage scenarios are conducted three times per year at every hospital, including 
two internally led exercises (one of these must test the full end-to-end process for the timely 
escalation,  request,  and  receipt  of  additional  supplies  from  external  providers)  and  one 
delivered by AtoE (our external training provider). In addition to this, other emergency scenarios 
are  also  undertaken  quarterly  via AtoE,  supplemented  by  locally  led  sessions  delivered  by 
Resuscitation Leads. Every year, at least one of these scenarios is undertaken out of hours. 
•  Emergency scenarios are derived from NHS guidelines and adapted to account for local major 
haemorrhage  protocols, including  escalation,  and  for  the requirements  for  higher  volumes  of 
blood products. Resident Doctors participate in the emergency scenarios.  

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
  
 
 Further actions across Nuffield Health:  

•  Ongoing review  of  policy  access  and  readership  analytics  will  be  used to  provide  assurance 

that Consultants and staff are engaging with critical emergency documentation.  

•  Emergency  scenarios  are  kept  under  review  and  amended  as  necessary  in  response  to 

learnings from incidents.  

•  The induction and Practising Privileges renewal checklists will be updated ensure Consultants 
are  aware  of  and  have  discussed  MyStaff  access  and  how  to  locate  all  relevant  policies, 
including local emergency protocols with a target date of June 2026. 

Matter of Concern 3 

The site manager was new and although there had been some training for her role, there 
was  a  lack  of  understanding  of  the  emergency  protocols  and this was  also  the  case with 
nurses  at  the  hospital  for  this  event.  A  very  senior  member  of  ambulance  crew  was 
attempting to assist the site co-ordinator as to locate the most relevant documents. Training 
needs to be embedded and protocols readily available.   

Nuffield Health’s Response:  

At the time of Incident:  

•  The  site  manager  was  new  to  the  role  but  previously  held  a  Senior  clinical  role  as  head  of 

department in the Hospital for 9 years prior.  

•  The  Transfusion  Policies  in  place  at  the  time  were  the  Aspen  Healthcare  Limited  Blood 
Transfusion  policy  and  the  Aspen  Healthcare  Limited  Major  Haemorrhage  Policy.  All  staff 
including the site manager had received training on these.  

•  The Aspen Healthcare Limited–Standard Operating procedure Notification of Patient Death was 
also in place. Unfortunately, there was a short delay in the site manager identifying this policy 
after Mrs Pytches had died and the actions required. This is the document referred to by HM 
Coroner in the concern raised above. The site senior management team then supported the 
site manager in contacting the Coroner to obtain authorisation to  release Mrs Pytches  to the 
offsite mortuary. 

Actions / Measures already in place across all Nuffield Health hospitals:  

•  As part of a comprehensive blood transfusion review in 2025, enhanced training requirements 
were  introduced  for  all  staff  involved  in  any  stage  of  the  blood  transfusion  and  major 
haemorrhage  pathway. Scenario-based  emergency testing  has  been strengthened,  including 
rehearsal of escalation and onward transfer processes. 

•  Major  haemorrhage scenarios  are  undertaken  at  least three times  per  year  at  every  Nuffield 
hospital  -  two  internally  led  exercises  (one  of  which  tests  the  full  end-to-end  process  for 
escalation and receipt of additional blood products from external providers) and one by AtoE. 
Additional emergency scenarios are delivered quarterly by AtoE and locally by Resuscitation 
Leads.  Scenario  outcomes  are  captured  via  a  structured  dashboard  and  reviewed  through 
pathology, transfusion, and governance forums, with action plans developed where learning is 
identified. 

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 •  As  part  of  emergency  scenario  testing,  assessment  of  staff  understanding  of  staff  protocols 

• 

available and location is assessed and audited.  
In  emergency  situations,  teams  are  expected  to  use  laminated  algorithms  available  on 
resuscitation trolleys, rather than relying on digital access. These tools are routinely reviewed 
for availability and clarity. 

•  At the Hospital, regular training sessions are carried out for site managers and site clinical leads, 

including access to protocols and how to access additional support if needed.  

•  Care  of  the  dying  policy  –  CL  62  issued  in  January  2025  and  has  been  updated  with 
recommendations from the Fuller Inquiry Part 2. Training for the policy has been undertaken at 
the hospital and rolled out across Nuffield Health. 

Further actions across Nuffield Health: 

•  Nuffield’s current major haemorrhage training module will be further developed to ensure clear 
end-to-end processes and highlighting differences from NHS pathways, with a target date of 
May 2026.  

•  Proposed new induction for site leaders, night coordinators, and senior nursing staff to be rolled-
out to ensure strengthened, structured, mandatory coverage of emergency protocols and role 
responsibilities, with a target date of end of June 2026.  

•  Scenario  testing  will  continue  to  test  not  only  clinical  response  but  also  documentation 
standards  and  team  role  clarity,  with  learning  reviewed  quarterly  through  established 
governance routes. 

•  The  major  haemorrhage  documentation  template  is  currently  being  developed  to  enable 
enhanced clarity of documentation during emergency incidents, with target date of end of June 
2026. 

Matter of Concern 4 

There was some confusion about the roles and responsibilities when there was a concern 
that an ambulance was required to attend to a major event to a private hospital where the 
patient was undergoing surgery in an operating theatre. Evidence was that Mrs Pytches was 
suffering from a major haemorrhage with an uncertain aetiology. There is a concern that Mrs 
Pytches did not regain stability such that she could have been safely moved and there was 
no  plan  as  to  whether  Mrs  Pytches  required  transfer  to  a  tertiary  centre.  Calling  an 
ambulance without an understanding of specifically what was required could impact on a 
future death taking this resource from a community emergency.  Mrs Pytches already had 
the  attendance  of  qualified  surgeons  and  anaesthetists  whilst  suffering  a  major 
haemorrhage that could not be treated by community paramedics, however well qualified 
and experienced as in this case.  

Nuffield Health’s Response:  

At the time of Incident:  

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
 
 
 
 
 
 •  Emergency services were called to enable an urgent transfer of Mrs Pytches to an NHS facility 
that could provide Level 3 care. This was an appropriate emergency response for the critical 
clinical situation, where the Hospital did not have on site Intensive Treatment Unit facilities.  A 
transfer  would  have  been  required  if  Mrs  Pytches  had  survived  and  it  was  prudent  and 
reasonable to make sure that this was available at the earliest possible opportunity.  

Actions / Measures already in place across all Nuffield Health hospitals:  

•  A defined escalation pathway exists for emergency events, including the involvement of senior 
clinicians and site management when ambulance attendance or transfer is being considered.  
•  Major  haemorrhage  scenarios  include  escalation,  communication,  and  decision-making 
elements,  and  at  least  one  scenario  annually  tests  ambulance  activation  and  transfer 
decision-making as part of the wider emergency response. 

•  Scenario  outcomes  are  reviewed  through  blood  transfusion  and  resuscitation  governance 
structures, pathology expert advisory groups, and national forums, with escalation to executive 
quality and safety committees where required. 
Introduction of SBARD - Situation Background Assessment Recommendation and Decision – 
which is a decision-based support tool to guide escalation and transfer discussions.  

• 

Further actions across Nuffield Health : 

•  Clarification  and  reinforcement  of  responsibilities  for  ambulance  activation  during  theatre 
emergencies will be included in local Standard Operating Policies and emergency guides. 

•  Transfer 

decision-making, 

including 
clinician-to-ambulance  service  communication,  will  be  explicitly 
scenario-based training. 

tertiary 

criteria 

for 

referral 

and 

incorporated 

senior 
into 

•  Ongoing  monitoring  will  be  undertaken  through  existing  audit  and  assurance  processes, 
Interim  Quality  Assurance  Report  requirements,  scenario  dashboards,  and 

including 
governance reviews. 

•  Reinforce  ambulance  activation  pathways  through  simulation  training  with  AtoE  input.  The 
scenarios  test  the  full  patient  journey  from  initial  recognition  of  deterioration,  structured 
assessment, escalation and intervention all the way through to the arrival of the ambulance and 
the  clinical  team  providing  handover  using  SBARD  (  Situation,  Background,  Assessment, 
Recommendation and Decision ). 

Monitoring and Governance 

Assurance will be maintained through: 

•  Audit of emergency protocol training compliance. 
•  Regular checks on availability and accessibility of emergency documentation. 
•  Evidence of Consultant access of updated policies through MyStaff. 
•  Review of scenario-based training outcomes and action plans through established governance 

forums. 

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026 

 
  
 
 
 
 Learnings from the review of the Regulation 28 report and the Inquest generally have been shared 
at the quarter 1 2026 Mortality and Morbidity meeting and cascaded out to MAC Chairs for sharing 
across all hospitals. 

We  hope  the  measures  we  already  have  in  place  and  the  planned  further  actions  collectively 
address  the  matters  raised  by  HM  Coroner  and  provide  assurance  that  any  risks  have  been 
mitigated and systems strengthened to reduce the risk of future harm. 

Yours sincerely, 

Chief Executive - Nuffield Health  

                                                                Date 06/05/2026 

Document: Nuffield Health Regulation 28 Response 
Ref: 2026-0164 
Date: May 2026