Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021.
The Coroner raised the following matters of concern in this case:
- East of England Ambulance Trust (EEAST) were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes.
- There were no emergency ambulances available to assign to this call due to high call demand.
- An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. 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.