Prevention of Future Deaths report: Barbara Hollis (3 October 2022)

Summary

Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital.

Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022.

Content

The Coroner raised the following matters of concern in this case:

• East of England Ambulance Trust (EEAST) were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect.
• The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes.
• At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours.
• There were no emergency ambulances to respond to the initial 999 call due to high demand on the service.
• It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients.
• However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur.

This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period.

• Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)
• Prevention of Future Deaths report: Christina Ruse (3 October 2022)