Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)

Summary

 On 3 August 2022, Geoffrey 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.        

The medical cause of death was:

1a) Sub Acute Myocardial Infarction

1b)  Coronary Artery Atherosclerosis

2) Hospital Admission for Post Operative lieus.

Content

Matters of Concern

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 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.

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