Brian Moreton
25 Sept 2023 · Coroner James Thompson · Newcastle upon Tyne and North Tyneside
The coroner's concerns
1. lack of access to patient medical notes
“Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON's case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone”
2. incorrect clinical assumption of improvement
“Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect.”
3. failure to refer for surgical opinion
“It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place.”
4. misleading impression of treatment effectiveness
“Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was comptemplated - this was not the case”
5. poor and misleading communications
“Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.”
Responses
2023-0352-Response-from-DAC-Beachcroft.pdf ↗· North Cumbria Integrated Care NHS Foundation Trust
Stated action · now
“North Cumbria now take part in a regular Inflammatory Bowel Disease MDT at Newcastle, which as you heard at the inquest, has improved communication between the two Trusts and enables clinicians to more freely pick up the phone and seek advice.”
2023-0352-Response-from-North-Cumbria-Integrated-Care-NHS-Foundation-Trust.pdf ↗· North Cumbria Integrated Care NHS Foundation Trust
Stated action
“The Trust has undertaken a thorough review of Mr [name redacted] care and the concerns raised within the Regulation 28 Report. A number of actions have been identified which will be implemented to address the concerns.”