An NHS hip op patient died after waiting more than 14 hours for an ambulance to transfer him between two Norfolk hospitals less than a mile apart.

Geoffrey Hoad, 86, had undergone the routine operation at the private Spire hospital in Colney. But three days later, while still recovering at the site, his condition deteriorated.

Staff called an ambulance to transfer him to the emergency assessment unit at the Norfolk and Norwich Hospital (N&N), a five minute drive away, but it took more than 14 hours for paramedics to arrive.

His condition continued to deteriorate and he died at the N&N hours later.

Eastern Daily Press: Jacqueline Lake, Norfolk's senior coroner

Following a three-day inquest into his death, the county’s senior coroner Jacqueline Lake, raised serious concerns about the incident.

“This is on the face of it a natural cause of death," she said. "However this is not a case where this adequately reflects all the evidence I have heard.”

She said she would be sending a Prevent Future Deaths (PFD) report to both the East of England Ambulance Service Trust and Spire Healthcare, and also contacting the secretary of state for health.

The case echoes two remarkably similar inquests last year in which patients undergoing routine operations at Spire died after their conditions deteriorated and they faced long ambulance delays to transfer them to the N&N.

Under an agreement reached during the pandemic, the private hospital treats many NHS patients, to help clear health service waiting lists.

Eastern Daily Press:

Ms Lake added: "Clearly, I do have concerns in this case. Waiting over 14 hours [for an ambulance] is not acceptable by any stretch of the imagination and these delays are continuing.

“The East of England Ambulance Service Trust has, and continues to, taken action in this respect to do what it can within its powers. However, the risk remains. 

“The risk of future deaths continues, and in such circumstances my duty is to make a report. 

“I do think this is a problem that the relevant government department may be able to resolve. I will also be making a report to the relevant secretary of state for health.” 

Eastern Daily Press: Spire hospital in ColneySpire hospital in Colney (Image: Newsquest)

She said Spire Healthcare had introduced measures to reduce delays to transfers.

“Steps are clearly being taken and while steps may be being taken nationally by Spire, Mr Hoad died over a year ago," she added.

“This problem has been continuing for longer than that and has been raised at previous inquests. 

“Upon that basis, and on the basis that Spire is continuing to rely on an NHS service which is clearly under great pressure and is clearly struggling to meet its time targets, delays are continuing. I have concerns that the risk of death continues.” 

Eastern Daily Press: Geoffrey Hoad and Ann McDowell

Mr Hoad, a retired company secretary from Wingfield, near Diss, had the surgery on August 3, 2022, under general anaesthetic, without complications.

When staff contacted the ambulance service on August 6, his condition was not considered life-threatening and his surgeon expected the transfer to be within two to three hours.

An ambulance was called at 6.16pm, and staff were advised that there was a delay of six hours, although evidence given in court revealed that waiting times were longer than this at that time. 

READ MORE: Norwich woman faced 20-hour ambulance wait, inquest hears

The service was called for again at 23.45pm with a view to speed up the response, but this did not happen. 

A final call was made for an ambulance at 7.38am on August 7 and was upgraded to requiring a response within 40 minutes. 

A paramedic arrived at 8.26am, more than 14 hours after the original call. 

Mr Hoad was transferred to the N&N at 9am, where he continued to deteriorate and died on the same day just before midnight. 

Eastern Daily Press: An ambulance from the East of England Ambulance Service Trust

His medical cause of death was given as a subendocardial myocardial infarction, also known as a heart attack, with coronary heart disease following hospital admission for post operative ileus.

Anne Saunderson, of Fosters Solicitors, who represented Mr Hoad's family at the inquest, said: "This is not the first time HM Coroner has issued warning notices in relation to a death involving significant delays in the provision of ambulances to transfer patients from Spire Norwich hospital to local NHS hospitals.

"Mr Hoad had to wait nearly 15 hours to be transferred one mile to the Norfolk and Norwich University Hospital and it has been disappointing to hear that the situation with ambulance delays remains largely unchanged.

"Decisive action is required by the secretary of state for health, East of England Ambulance Service Trust and Spire Hospital to address this issue and ensure future deaths are preventable."

Eastern Daily Press: Norfolk Coroner's Court at County Hall, NorwichNorfolk Coroner's Court at County Hall, Norwich (Image: Newsquest)

A spokesman for the ambulance trust said: "We would like to offer our sincerest apologies to Mr Hoad’s family for the delayed response.

"We acknowledge the coroner’s report and will consider it carefully.

"At the time of this incident the trust was under significant pressure due to 999 call volume and delays with releasing ambulances from hospitals.

"Since the start of 2023 our response times have improved due to work to improve the number of frontline staff and available ambulances, but we recognise there is a lot more work needed by us and our partners to improve our response to patients.

"Our thoughts remain with the family and friends of Mr Hoad at this time."

Eastern Daily Press:

A spokesperson from Spire Healthcare added: "Spire Healthcare offers our sincere condolences to the family of Mr Geoffrey Hoad for their loss.

"Spire continues to work closely with the ambulance Service and local NHS trusts on ways to ease delays for patients receiving care."


This is not the first time a death such as Mr Hoad’s has occurred.  

In February 2021, 71-year-old Barbara Hollis died after undergoing a knee replacement.  

Ten months later and the issue produced the same result, when 79-year-old Christina Ruse died following a hip replacement.   

In each case, ambulances were not available to collect them from the Spire hospital and their conditions deteriorated.

Both women died after eventually arriving at the nearby N&N.

READ MORE: Ambulance tragedy was 'an accident', coroner rules

In the case of Mrs Hollis, there was a one-hour and 36-minute wait between an ambulance being called and arriving.

For Mrs Ruse, the delay was one hour and 27 minutes, by which time she was taken back into the operating theatre.

She was not taken to the N&N until three hours and 12 minutes after the ambulance was called for.