Geoffrey Moyse

Brighton & Hove Integrated Care Service

Fourth Floor

177 Preston Road
Brighton

BN1 6AG

Telephone: 01273 560243

Veronica Hamilton-Deeley

HM Coroner for Brighton & Hove
The Coroner's Office

Woodvale

Lewes Road

Brighton

BN2 3QB

Dear Madam,
Re: Regulation 28 Report; Mr Geoffrey John Moyse

Thank you for sending me the Regulation 28 report arising from the death of Mr
G.J Moyse, and providing us with the opportunity to respond to the matters of
concern. It was with deep sadness that | read about the circumstances leading up
to the death of Mr Moyes and | would like to pass on my condolences to Mrs
Moyes. We have reviewed our involvement in Mr Moyes care and have outlined
below the actions Brighton and Hove Integrated Care Service propose to take.

Brighton and Hove Integrated Service provided the Referral Management Service
for Brighton and Hove between March 2009 and August 2015. Our role was to
receive patient referrals from GPs and to safely steward patients to the hospital of
their choice. During the period in question we worked closely with the CCG and
were aware of discussions between BSUH and the CCG about long waiting times
for digestive diseases services. We therefore paid particular attention to advising
patients of these long waits, we also offered them alternative hospitals where more
timely NHS care and appropriate treatment could be provided. This included other
NHS hospitals and independent sector hospitals.

Whilst not directly involved in discussions with BSUH and the CCG regarding
digestive diseases, we worked closely with the CCG to ensure delays in patient
care were minimised during a period of long waiting times in the focal NHS
Hospital.

www.bics.nhs.uk

ee Joint Clinical Lead for the service at the time) has reviewed .

our involvement with Mr Moyes and | have attached an investigation report which |
hope addresses the matters of concern that you have identified. In particular it
found that the Referral Management Service swiftly handled Mr Moyes’ referrals,
actively sought options and encouraged him to be seen as soon as possible at a
convenient location of his choice. Our records show that our Patient Care Advisor
was concerned about his decision to wait longer for treatment and this was shared
with his GP. Our investigation also showed that the pathology-report and all the
other referral documents dated the 26" July were faxed to the Nuffield on the 5"
August, at the request of the patient and the GP. In addition an urgent referral was
sent to Royal Sussex County Hospital. If required | can forward dated copies of
faxes sent and records of conversations with Mr Moyes. If you have other evidence
that this was not the case it would be useful if this was shared in order to aid any
further investigation we may need to do.

in this case, | am satisfied that we followed our protocols and demonstrated best
practice in our role in Mr Moyes’ care however there is always learning from any
incident of this kind. As a resus our Director of Clinical Services,
has used Mr Moyes’ case as an anonymised example for discussion with our
Patient Safety Group, where staffs are represented from all of our service areas.
The group has reviewed this case with the intention of identifying any
improvements that can be made, building staff awareness of the importance of
providing patient choice and building upon the patient safety focused approach. As
a result they are ensuring that all teams who offer choice in our services are
implementing our protocols for when patients choose to delay their care. The team,
like me, was deeply saddened by the ultimate outcome and were provided with a
powerful reminder of the importance of the work they do for patients.

| am happy for you to share this response with Mrs Moyes, if you see fit, and also

please do not hesitate to contact me if you believe that my response does not fully
address the concerns raised.

aon

Zoe Nicholson
Chief Executive

c.c Dr Christa Beesley, Chief Clinical Officer, Brighton and Hove Clinical
Commissioning Group

Miss Amanda Fadero, Interim Chief Executive, Brighton and Sussex University
Hospital Trust.

Brighton and Sussex [A'/@ £5
Our Ref: GF/MLS/C9/15/133/GFO25 University Hospitals

12 May 2016 RECEIVED)
The Ri | nty Hospital
6 MAY 2016 oval Sussex oe oetern Road
pike ee Brighton
Miss V Hamilton-Deeley, HM Senior Coroner — BN2 5BE
Coroner's Office Tel: 01273 696955
Woodvale, Lewes Road
BRIGHTON
BN2 3QB

Dear Miss Hamilton-Deeley

The Late Geoffrey Moyse, date of birth: 28 May 1937
NHS No: 614 443 4380

Thank you for both your Regulation 28 reports of 19 February 2016, and for
drawing all your concerns to the attention of the Interim Chief Executive of
this Trust as well as to Caroline Davies, Deputy Chief Nurse. This response is
being provided jointly by both the current Chief Executive, Dr Gillian
Fairfield, who took up post at the start of April 2016, and

As you know, Brighton and Sussex University Hospitals NHS Trust is always
willing to review our services, in order to identify improvements which can
be made in the light of experience.

The Trust recognises that fragmentation of healthcare increases the
opportunities for delays, breakdown in communication and potential
compromise of effective patient care. However, the local NHS health
economy is bound by the decisions of Clinical Commissioning Groups as to
where patients may be referred for investigations and treatment, and how
any imaging or histology which may be relevant to multidisciplinary team
discussion is made readily available. Private providers of services are at
liberty to choose to which laboratory specimens are submitted for reporting.
This fragmentation is increasing. It is extremely disappointing that since
January 2016, some histology work which used to be sent to the laboratory
of this Trust from a local private hospital is now being sent elsewhere, and
other privately run organisations were already doing this.

The Trust has been very conscious of the considerable difficulties in
providing timely abdominal surgery appointments. A new Clinical Director of
Abdominal Surgery and Medicine took up post in December 2015, and has
already implemented several changes to improve the effectiveness of this
service. Since the death of Mr Moyse, three new surgical consultants have
taken up posts in the department and another Colorectal/Emergency
surgeon is due to start in June 2016. We anticipate there will no
requirement for Locum Consultants from June 2016.

With our partner
brighton and sussex
medical schoo!

We deeply regret that there was some delay between the decision in the
morning that Mr Moyse was ready for discharge home, and the provision of
the discharge letter and the relevant medication so that he could actually
go home later that afternoon. It is very disappointing to learn that Mrs
Moyse did not feel adequately consulted about the discharge planning for
her husband, especially as the likelihood that Mr Moyse would be ready for
discharge had been identified on the day before he was actually discharged.

We acknowledge that it was unacceptable for the discharge sheet, known as
the “purple planner” not to have been completed, but more importantly
than how this was documented, we accept that the communication with Mr
Moyse’s family was itself inadequate. As you may know, the Head of Nursing
- Discharge, Partnerships & Clinical Site Management left this Trust in
February 2016 after being recruited to a post elsewhere. The Trust has since
appointed an experienced senior nurse to undertake this role, and she will
move into the post later this month. This will give a good opportunity for a
review by fresh eyes on how staff are taught about the requirements of the
Trust’s very thorough discharge policy, including the importance of good
communication and documentation.

Thank you once again for raising your concerns with us.

Finally, please pass on our condolences to the family and friends of Mr
Moyse on their sad loss.

Yours sincerely

Dr Gillian Fairfield
Chief Executive Deputy Chief Nurse, Patient Experience

NHS)

Brighton and Hove
Clinical Commissioning Group

Miss V Hamilton-Deeley
H M Senior Coroner RECEIVED

W e coroner's Office {2 MAY 2016 Level 4, Lanchester House
ooadvaie Trafalgar Place
LewesRoad sf Ce wewenewce \ Brighton
Brighton BN1 4FU
BN2 30B
Tel: 01273 574863
Fax: 01273 574737
mail: christa.beesley@nhs.net
Web: www.brightonandhoveccg. nhs. uk
9 May 2016

Dear Miss Hamilton-Deeley
Regulation 28: Report to prevent future deaths: Geoffrey John MOYSE

| am writing in response to your Regulation 28 Report to Prevent Future Deaths regarding the
late Geoffrey John MOYSE following the inquest you held on 17 February 2016. | would firstly
like to extend my condolences to Mr Moyse’s family on behalf.of the Clinical Commissioning
Group (CCG). | have taken this opportunity to provide you withian update on the areas of
concern which you have identified in your Record of Inquestifos which:the:CCG has. - .
responsibility. : :

You identified that there had been a delay in Mr Moyse reagiying-asgessment and treatment
within secondary care because of prolonged waiting times within: the Digestive Diseases
department at Brighton & Sussex University Hospitals (BSUH). As you know there remain
considerable and long standing challenges regarding waiting time performance within BSUH
for the NHS constitutional target of 18 weeks from referral to treatment. The CCG is working
closely with BSUH and primary care in the city with the aim of reducing the waiting times for
secondary care whilst improving the patient experience and reducing the risk of any patient
experiencing harm. The CCG has developed an overarching Referral to Treatment recovery
plan which includes both BSUH internal actions and those owned by the CCG. This action
plan is subject to monitor and review by the System Resilience Group (SRG) which is a
multi-agency group of senior health and social care leaders from across the local health
economy including regulators from NHS England and NHS Improvement and with input from
Healthwatch Brighton and Hove. A key element of the recovery plan is the aim to secure
additional secondary care capacity in both the independent sector and other NHS providers
across Sussex and beyond, to support improvement in waiting times. Brighton & Hove CCG is
undertaking this task in partnership with other CCGs serving the BSUH catchment area.

Page 1 of 3

fealth For Our City |

The CCG is currently reviewing individual clinical pathways in conjunction with providers to
enable increased numbers of interventions to be undertaken within primary care or
community services and prevent inappropriate referrals to hospital based secondary care. In
order to support these developments and ensure clinical leadership, oversight and
governance Brighton & Hove CCG in partnership with CCGs in Horsham and Mid-Sussex and
High Wealds, Lewes Havens and BSUH have established a clinically chaired Planned Care
Board. This Board is chaired by clinical leads and is currently reviewing individual clinical
areas and associated care pathways in conjunction with secondary care clinicians to ensure
they are as smooth as possible for patients to negotiate and outcomes are optimised.

You will no doubt be aware that CCGs, Local Authorities and NHS provider trusts have been
mandated to work together across regional footprints to formulate Sustainable Transformation
Plans (STP) which aim to identify the system issues around care, quality and finance at a
regional level. Brighton and Hove are working in a regional footprint with colleagues from
across Sussex and East Surrey. One aim of the STP will be to formally recognise the
challenges in delivering high quality timely care for the city’s population solely within Brighton
and Hove and plan to develop regional solutions to ensure a more sustainable health and
social care economy. These plans are underway and final submissions will be concluded
within June.

In addition to these actions, the CCG's Quality Team closely monitor the impact on patient
care and patient experience of the-extended waiting times for referral to treatment within
secondary care. The CCG chair the Quality Review Meeting with BSUH held monthly where
extended waiting times and their impact is monitored. The CCG has received a Serious
Incident report from BSUH related to the extended waiting times for treatment and the lessons
from this report have been incorporated within the overarching programme of work. The CCG
is also facilitating a clinically led scrutiny panel reviewing those patients care who have waited
longer than 52 weeks for treatment following referral.

Since Mr Moyse sadly passed away there has been a change in the delivery of the Referral
Management System within the City which is now provided by Optum. As you may be aware
there have been initial difficulties with the current provider coupled with national challenges
relating to the electronic referral system for primary care to refer to secondary care. The CCG
has been working very closely with the new provider over recent months to ensure an
appropriate level of service. Actions taken to date have included issuing a performance notice
to the provider and close performance and contracting monitoring. The CCG continues to
work closely with the provider to ensure patients are offered choice as to where they wish to
receive secondary care treatment. This is to ensure the CCG fulfills its obligations to offer

- patient's choice but to support patients to receive their treatment in a timely fashion by
offering services outside of Brighton and Hove.

Page 2 of 3

In your report you highlighted a possible disconnect between independent sector hospitals
and NHS provision relating to results of investigations and questioned whether they are
routinely made available to clinicians within NHS provision. The CCG currently has service
specifications in place with all independent sector providers which cover commissioners
expectations regarding onwards referrals, tracking results and highlight best practice and
national guidelines.

As the CCG seeks to secure additional capacity via the processes outlined above, the Urgent
and Planned Care Team will ensure that service specifications are reviewed and fit for
purpose including clarity around the handling of incidental findings of cancer and that any
independent sector providers are linked to the local wider multi-disciplinary team for cancer
care and treatment.

| hope you find this response sufficient in answering the areas identified.

Yours sincerely

Christa Beesley
Chief Clinical Officer
Brighton & Hove Clinical Commissioning Group

Page 3 of 3