Dear Ms Lake, am further to the inquest into the death of Geoffrey Hoad, which concluded on September 2023. Following which you made Regulation 28 Preventing Future Death Report and this is the Trusts' response to that report: understand that you heard evidence from AOC Patient Safety Manager; during inquest in relation to the actions 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, WWW eastamb nhsuk #WeAreEEAST Way writing the the

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 R' =0.9521 02,52.48
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00.57.36 0o.28.48 QO.DO OQ 1000 2000 300O 4000 5000 GOOO 7000 8000 Hours lost due t0 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 NHSEII 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 13th October 2023 in Norfolk and Waveney: 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 reduced by 29 minutes 39%) this September compared to last and C3 response times having reduced by 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:

Dear Madam

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).

3 Dorset Rise London EC4Y 8EN

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

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

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,

3 Dorset Rise London EC4Y 8EN

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

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.

3 Dorset Rise London EC4Y 8EN

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

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

3 Dorset Rise London EC4Y 8EN

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

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.

3 Dorset Rise London EC4Y 8EN

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

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:

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

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