The death of a 63-year-old woman at a private hospital has sparked concerns about how medics responded to a fatal haemorrhage while she underwent spinal surgery.
Julie Pytches died on October 14, 2023, in the operating theatre at Nuffield Health’s Holly Hospital in Buckhurst Hill during elective surgery.
However, there was an arterial bleed that caused major haemorrhage and led to cardiac arrest. Mrs Pytches’ medical history and post-mortem examination identified no natural cause of the haemorrhage.
The conclusion of the inquest on October 30, 2025, was “misadventure secondary to spinal surgery”.
Essex coroner Sonia Hayes has raised a number of concerns around the hospital’s response, while making it clear these matters did not contribute to her death.
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An anaesthetist who responded to the emergency crash call had “limitations on his ability to participate in resuscitation”, and there was confusion about the protocol and procedures at the Holly Hospital – doctors may practice in more than one hospital, which “may cause confusion as to what is required in individual hospitals within the group”, she said.
She said training needs to be embedded, and emergency protocols need to be “readily available” to avoid a repeat of a senior member of an ambulance crew having to assist the site co-ordinator in locating the most relevant documents.
There was also confusion about roles and responsibilities when a concern arose that an ambulance was required to attend.
She added: “Calling an ambulance without an understanding of specifically what was required could impact a future death, taking this resource from a community emergency.
“Mrs Ptyches already had the attendance of qualified surgeons and anaesthetists whilst suffering a major haemorrhage that could not be treated by community paramedics, however well qualified and experienced as in this case.”
A Nuffield Health Spokesperson said: “Our deepest sympathies are with Mrs Pytches’ family. We fully cooperated with the coroner’s investigation. While the Coroner is clear that the matters raised in the Regulation 28 report did not contribute to Mrs Pytches’ death, we understand they have been highlighted with the intention of preventing future incidents.
“Patient safety is our highest priority, and we are reviewing the points raised by the Coroner to determine our response”
