Brian Moreton

4 December  November 2023 

Mr James Thompson 
HM Assistant Coroner for Newcastle Upon Tyne and North Tyneside 

Dear Sir 

Inquest touching upon the death of Brian David Moreton 

We write further to this inquest, in relation to the Regulation 28 report which was issued to North Cumbria 
Integrated Care NHS Foundation Trust, as we are aware that the deadline for North Cumbria responding 
is this week and some of the concerns you raised were around communication from North Cumbria to the 
Newcastle upon Tyne Hospitals NHS Foundation Trust.  

Whilst  we  appreciate  that  the  Regulation  28  report  is  not  directed  to  our  client,  we  wanted  to  take  the 
opportunity  to  clarify  Newcastle's  position  around  communication,  which  will  hopefully  assist  with 
addressing some of the concerns you had. As you heard at the inquest, when a patient, such as Mr Moreton 
is admitted to North Cumbria under the Gastroenterology team, the Gastroenterology team are deemed to 
be the leading clinicians, irrespective of any other ongoing treatment or underlying conditions. As in this 
case,  there  may  be  circumstances  where  a  patient,  such  as  Mr  Moreton,  are  already  in  the  care  of  an 
Oncology  team,  prior  to  and  whilst  receiving  inpatient  Gastroenterology  treatment.  In  this  scenario,  the 
Acute  Oncology  Nurses  (employed  by  North  Cumbria)  and  Oncology  Advanced  Care  Practitioner 
(employed  by  Newcastle)  may  visit  existing  oncology  patients  whilst  on  the  Gastroenterology  ward  to 
provide them with support and update the Oncology Team about their admission. If any direct advice is 
required by Gastroenterology specialists from the oncology team around matters such as, life expectancy 
when considering a patient's prospects of surviving gastroenterology surgery, then the process is for the 
relevant treating doctor to contact the Consultant Oncologist directly, and not to rely solely on oncology 
nursing input. This applies to any area of medicine where a cancer patient is admitted. 

If  specialist  advice  is  required  in  relation  to  the  management  of  colitis  and  any  potential  complications 
arising from this, even when the colitis is as a result of immunotherapy for the treatment of a melanoma, 
advice  would  be  sought  by  the  treating  Gastroenterology  team  at  North  Cumbria,  from  the 
Gastroenterology team at Newcastle (as the tertiary centre), as the Gastroenterologists are the specialists 
dealing with colitis and any complications arising from this. This is why, following Mr Moreton's death, 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.  

We  trust  that  the  above  clarifies  the  position  and  provides  you  with  some  reassurance  about  the 
communications processes between the Trusts, but should you have any queries, please do not hesitate 
to contact us.  

Your sincerely 

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04 December 2023 

PRIVATE AND CONFIDENTIAL  
Mr James Edward Thompson 
HM Assistant Coroner for the Coroner Area of Newcastle and North Tyneside 
Coroner's Office 
Lower Ground Floor 
Block 1 
Civic Centre 
Barras Bridge 
Newcastle upon Tyne 
NE1 8QH 

Dear Mr Thompson 

Re: North Cumbria Integrated Care’s Regulation 28 Response and Action Plan 
Concerning the Inquest into the death of Mr Brian Moreton 

I write following the inquest that you resumed on 21/09/2023 and 22/09/2023 into the death of Mr Brian 
Moreton at the Newcastle Upon Tyne Coroner’s Court.  You concluded that Mr Moreton sadly died on 
06/05/2022 at the Freeman Hospital in Newcastle Upon Tyne with a medical cause of death of: 

1a Cytomegalovirus Colitis and Invasive Aspergillosis  
1b Treatment of Immune Checkpoint Inhibitor Colitis 
1c Immunotherapy for Metastatic Malignant Melanoma 

A Narrative Conclusion was recorded, together with a finding of Neglect.   

During the inquest, you remarked on the candour of the North Cumbria Integrated Care NHS Foundation 
Trust (“the Trust”) witnesses and their commitment to addressing any areas of concern.  Notwithstanding 
this, the evidence identified a number of concerns that you felt may lead to future deaths if action is not 
taken by the Trust, and your statutory duty to issue a Regulation 28 Report to the Trust was therefore 
engaged.  I was saddened to learn of the circumstances surrounding Mr Moreton’s death and on behalf 
of the Trust, I wish to extend my sincere condolences to his family and friends.   

I am grateful to you for raising your concerns to me.  It is imperative to the Trust that safety issues are 
identified and rectified to ensure our services are safe and effective.   

The Trust has undertaken a thorough review of Mr Moreton’s 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.  These aim to prevent another safety incident (of same kind or similar kind) from occurring, 
and thus, prevent future deaths.   I am grateful to you for the extension of time you have afforded to the 
Trust to ensure a robust review and response. 

Please accept this letter as the Trust’s formal response to the Regulation 28 Report.  Each concern is 
addressed however may not appear in the same order as set out in the Regulation 28 Report.  Please 

Safe, high quality care every time 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 find enclosed the Trust’s corresponding action plan which incorporates the identification and embedding 
of all learning relevant to Mr Moreton’s case, whether identified by the Regulation 28 Report or not. 

Concerns 1 and 2  

Evidence was heard that at the time of the inquest radiologists do not have access to a patient’s 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  referral 
followed by a summary document which can be at odds with each.  

It  is  of  concern  that  the  use  of  telephone  referral  system  and  summary  could  contain  errors  and  the 
radiologist must rely on this information, with no quick way to inspect a patient’s notes. 

The inquest heard that referrals to Radiology for imaging were made electronically, in writing, on the ICE 
system.  To ensure compliance with the Ionising Radiation (Medical Exposure) Regulations (“IRMER”) 
2017 and in line with the Trust’s ICE User Guide for Radiology requests, the ICE system requires the 
referrer to provide the following details within the ICE referral: 

  Patient demographics;  
  Confirmation that the criteria for the imaging has been met;  
  Referrer details including their name, role and contact details;  
  Clinical details where symptoms, observations and past history should be recorded;  
  Global clinical details.  This an area where the referrer may type in any further information that 

has not been previously captured but it is limited in characters;  

  How the patient will attend for their imaging; 
  Priority of the imaging; and 
  Location of where the results should be sent. 

This ensures that for any requests for CT, MRI, or ultrasound scans, the Duty Radiologist has sufficient 
information from the referrer that the benefits of exposing the patient to ionising radiation outweigh the 
risks, and that this can be justified.  The above details also subsequently assist the Reporting Radiologist 
to interpret and report on any imaging carried out, as they may not be the same practitioner as those 
justifying the imaging.  The ‘Clinical Details’ box within the ICE system is a mandatory field, with unlimited 
free text, where the referrer ought to include anything of clinical importance to assist in the justification 
and  interpretation  of  the  imaging.    Whilst  the  Trust’s  ICE  Guide  sets  out  that  that  symptoms, 
observations, and past history should be recorded  within the clinical details box, it is the professional 
judgement of the referrer to make a decision on what is clinically relevant to the referral, to ensure the 
imaging is justified and the interpretation of it is meaningful. 

The inquest heard that a whole body imaging CT scan for Mr Moreton was justified on 02/03/2022.  The 
ICE referral requested that the imaging assess for progressive disease (due to his diagnosis of BRAF 
mutant  metastatic  melanoma  and  due  to  a  re-staging  CT  already  pending  on  ICE  at  that  of  his 
attendance  to  ED)  and  to  rule  out  a  bowel  obstruction  (due  to  the  presentation  that  precipitated  his 
attendance  at  ED).    Mr  Moreton’s  history  and  some  symptoms  were  provided  within  the  referral, 
however, it was accepted in evidence that the referral omitted to include the history of a fever and toxic 
megacolon was not identified as a differential diagnosis.  The inquest further heard that had the referral 
included  the  symptom of fever,  it  might  have  altered  the  Reporting  Radiologist’s  interpretation  of the 
imaging. 

At the time of Mr Moreton’s admission, for urgent CT, MRI, or ultrasound scans, it was common practice 
within the Trust for the referrer to discuss the request with a Radiologist via the duty telephone line, to 
assist the Radiologist in making a decision as to whether the imaging could be justified.  Discussions 
with the Radiologist were in addition to the written referral on ICE (i.e. one did not replace the other) and 
were  not  documented  or  electronically  recorded.    Furthermore  and  as  aforementioned,  it  was  not 

2 

 
 
 
 
 
 
 
 
 
 guaranteed  that  the  Radiologist,  who  justified  the  imaging,  was  the  Radiologist  who  subsequently 
interpreted and reported on the scan.  Hence why it  was crucial for the referral on ICE to capture all 
clinically relevant information.   

In August 2022, the Trust ratified a protocol, which sets out a clear referral flow chart for the authorisation 
of CT imaging for adults.  If a CT scan is indicated, the patient must be reviewed or discussed with a 
senior decision maker within the referring team, and the referrer must make a written referral on ICE (as 
is the process for all imaging), with reference to who the senior decision maker is within the referral.  If 
the  request  falls  within  the  Rapid  Radiology  Request  Pathway  (“RRRP”)  criteria  below,  this  can  be 
discussed  with  a  CT  Radiographer  without  the  requirement  to  discuss  this  with  a  Radiologist  or  the 
referrer: 

  Unenhanced CT head  
  Unenhanced CT cervical spine 
  Unenhanced CT of the kidneys, ureters and bladder 
  Trauma “Pan Scan” (head/neck/chest/abdomen/pelvis) – up to 150mls non-ionic contrast media 
  Unenhanced  localised  CT  to  assess  for  fracture  (thoracolumbar  spine/pelvis/appendicular 

skeleton) 

  Acute aorta – pre and post contrast of the full aorta with 100mls non-ionic contrast media 
  CT pulmonary angiogram – post contrast scan with up to 100mls non-ionic contrast media 
 

“Surgical abdomen” – post contrast up to 100mls non-ionic contrast media 

Furthermore, there is no longer the expectation or requirement for referrers to discuss referrals for any 
imaging  with  a  Radiologist.    Whilst  the  duty  line  is  still  operational  for  referrers,  Radiographers  and 
Radiologists to discuss any requests being made, it is process for a robust ICE written referral to be 
made, and it is on that basis that the majority of imaging requests are justified or rejected, either by a 
Radiographer or Radiologist (depending on the above criteria), without the need for further discussion.   

If the protocol was operational at the time of Mr Moreton’s admission and had malignancy not featured 
within his presentation, it is likely he would have met the RRRP criteria for a surgical abdomen CT, as 
the Emergency Department (ED) assessed that he had symptoms concerning for bowel obstruction.  An 
ICE referral therefore would have been made and a CT Radiographer could have authorised this without 
the requirement to discuss this with a Radiologist or the referrer.  However, a whole body imaging CT 
scan to assess for progressive disease and to rule out a bowel obstruction would not have met the RRRP 
criteria.    An  ICE  referral  therefore  would  have  been  made  and  a  Radiologist  could  have  justified  or 
rejected the imaging on the basis of the written referral.    

A referral should sufficiently transfer pertinent information between referrer and provider without loss of 
content or meaning.  The protocol therefore intends to reduce the need for supplementary telephone 
discussions  with  a  Radiographer  or  Radiologist,  and  instead  emphasises  the  need  for  robust  written 
referrals on ICE.  This reduces the risk of the written and telephone processes being at odds with each 
other, makes it more efficient for the referrer and the Radiology Department, and ensures a decision on 
a patient’s care pathway is made as timely as possible to inform the clinical plan.  The protocol however 
also  emphasises  that  advice  can  be  sought  or  a  request  can  be  clarified  between  the  referrer  and 
Radiology Department utilising the duty line if needed.  

The Trust recognises that if most requests for imaging are managed via written referral on ICE, there is 
a need to ensure that such referrals are robust.  A robust referral  should contain high-quality clinical 
information, which enables the Radiology Department to determine the most appropriate investigation 
or procedure to be selected, that takes into account patient safety, radiation exposure, and diagnostic 
value.  It also provides a reason for the investigation through a clear diagnostic question that the referrer 
wants  answering,  to  assist  the  Radiologist  in  the  interpretation  of  results,  minimising  perceptual  and 
interpretational diagnostic errors, and the subsequent completion of a pertinent and concise report.   

An  educational  programme  is  therefore  being  developed,  with  support  of  the  Trust’s  Education  and 
Training Department, to provide a learning package for diagnostic referrals within the Trust (including 

3 

 
 
 
 
 
 
 
 
 Pathology  and Radiology requests).  The package, available to all staff who  have completed referral 
training,  aims  to  provide  examples  of  what  a  robust  diagnostic  referral  looks  like,  and  to 
highlight/emphasise: 

  What mandatory fields need to be completed; 
  The need for clear clinical information to be provided; 
  The need to provide a differential diagnosis. 

Such  training  would  emphasise  the  need  to  include  Mr  Moreton’s  symptoms  of  fever  and  profound 
diarrhoea within the clinical details box on ICE, as a potential red flag for a complicating features of acute 
severe colitis.   

The purpose of diagnostic imaging is to assist in the process of identifying or determining the etiology of 
a disease or condition, alongside the evaluation of a patient’s history, physical examination, and review 
of laboratory data.  Reaching a diagnosis provides a trajectory of treatment and an understanding of a 
patient’s prognosis, and in some cases, may be useful for preventative treatments.  However, in order 
to justify diagnostic imaging (to provide assurance that the benefits outweigh the risks) it is necessary to 
provide a differential diagnosis, which the imaging seeks to evidence or rule out.  A differential diagnosis 
of  query  obstruction  was  included  within  Mr  Moreton’s  ICE  referral,  but  toxic  megacolon  was  not 
considered as an explanation for his presentation during his admission.   

The  Radiology  Department  has  therefore  implemented  an  immediate  change  within  the  ICE  referral 
system.  The ‘Clinical Details’ box is  now titled ‘Order Clinical Details and Differential  Diagnosis’ and 
remains a mandatory, unlimited field.  Whilst this new field within ICE alone would not necessarily give 
rise to a referrer or the Radiology Department identifying the presence of toxic megacolon in a similar 
presentation  in  the  future,  the  field  is  a  further  prompt  to  the  referrer  to  further  analyse  the  patient’s 
symptoms to really think about any potential diagnosis and ensure this is included within the ICE referral.  
This aims to reduce the rate of interpretational error.  The absence or misrepresentation of a differential 
diagnosis carries the risk of the findings being interpreted as caused by a different condition (albeit with 
same or similar findings).   

A  standard  operating  procedure  (SOP)  is  in  the  final  stages  of  development  for  the  management  of 
inflammatory  bowel  disease  (IBD),  including  the  general  management  of  acute  severe  colitis  of  all 
causes.  The SOP includes red flag symptoms for acute severe colitis, and makes regular reference to 
the  need  for  clinicians  to  be  cognisant  of  high-risk  features  and  devastating  complications  of  severe 
colitis, such as toxic megacolon.  The SOP provides education that toxic megacolon is characterised by 
radiographic distension of the colon often with fever, tachycardia, neutrophil leucocytosis and anaemia.  
Once ratified the SOP will be electronically accessible to all clinical teams via the Trust’s Clinical SOPs 
intranet page.  Therefore, any clinician encountering a similar presentation to that of Mr Moreton’s, ought 
to refer to the SOP, which provides a step-by-step plan of care and a detailed section around presenting 
features, to help support assessment, diagnosis and management of IBD.  

The  introduction  of  the  differential  diagnosis  box  on  ICE  and  the  SOP  supports  the  educational 
programme in highlighting what constitutes clear clinical information and red flags for a diagnostic referral 
in  a  differential  diagnosis  of  IBD,  which  needs  to  be  included  within  the  ICE  referral  to  assist  in  the 
justification and reporting of any requested imaging.  

The inquest heard that Radiologists triaging and reporting on Mr Moreton’s imaging on 02/03/2022 did 
not have access to the relevant records.  The Trust has a number of Electronic Patient Records (EPR) 
across its services.  Inpatient, outpatient and community care also utilise paper records.  On attendance 
to  the  ED  on  02/03/2022,  Mr  Moreton’s  records  would  initially  have  been  in  paper  format,  and  later 
scanned to the ED’s EPR, Symphony.  Within the Trust, post-holders are only granted access to systems 
relevant  to  their  role/service  in  line  with  the  Trust’s  information  governance  policies.    Furthermore, 
Radiology Departments are not an outlier and it is not common practice nationally within the NHS for 
Radiology staff to independently  obtain information to assist them in the justification and reporting of 
imaging; the process is reliant on the information provided by the referrer.  Therefore,  Radiology staff 
did not have access to Symphony at the time of Mr Moreton’s admission, and due to the operational 
4 

 
 
 
 
 
 
 
 
 pressures  within  the  Radiology  Department,  it  would  not  have  been  feasible  or  considered  normal 
practice for any Radiologist on shift to leave the department to speak to a referrer or review the EPR or 
paper records, within the referring department.  Practice and operational pressures remain the same in 
November 2023. 

The Trust recognises the benefits of fit-for-purpose digital tools and technologies designed to manage 
patient information and make it easily available for our staff and patients.  As of June 2023, Symphony 
Paperlite has now been implemented in the EDs across the Trust’s acute hospital sites and the Urgent 
Treatment Centres.  Patient information in ED is now recorded directly onto Symphony, removing any 
paper records and the need for any specialism to have to attend the department to view the records.  
Digital transformation work is also underway to implement an EPR within the inpatient hospital setting.  
The EPR will replace some inpatient and outpatient paper records and legacy paper case notes will be 
digitised into a digital repository.  The Trust’s EPR project was launched in April 2023, but the process 
of procuring and implementing an EPR of the scale required for the Trust will take several years.  The 
project anticipates the process of securing the funding to continue until Spring 2024, with phase one of 
the implementation to commence by March 2026.   

Whilst it  would not be commonplace for Radiology staff to access records in the process of triage or 
whilst interpreting and reporting on imaging, the Trust recognises that in exceptional circumstances, it 
may be of benefit.  Radiology staff have therefore already been granted access to the Clinical  Portal, 
which is an EPR and contains primary care information and past medical history.  Access has also been 
granted  to  WebV,  which  is  an  inpatient  EPR  and  provides  access  to  a  patient’s  pathology  results, 
vitals/NEWS scoring and nursing assessments.  The Trust is in the process of granting Radiology staff 
access to Symphony Paperlite, and access will also be granted to the new EPR once commissioned.  A 
guideline needs to be produced on when records should be accessed in line with the Royal College of 
Radiologists.   

Concern 3 

The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where 
those  clinicians  receiving  the  referral  seldom  were  the  clinicians  who  carried  out  the  imaging.  The 
inference was the arrangement was susceptible to error. 

The inquest heard that each Radiologist on shift was expected to cover the duty line for 2 hours as the 
expectation  that  referrers  would  discuss  all  requests  for  urgent  CT,  MRI  or  ultrasound  scans  with  a 
Radiologist, resulted in the department receiving a large volume of calls.  At the time of Mr Moreton’s 
admission,  only  2  Radiologists  would  be  on  shift  with  shared  duties  for  managing  the  duty  line  and 
reporting  on  imaging.    There  was  an  expectation  that  Radiologists  reported  on  all  acute  images 
performed  during  their  2  hour  duty,  within  the  same  duty  period.    A  re-staging  scan,  particularly  for 
melanoma, is notoriously complex and ordinarily is afforded 14 days to report on.  However, any imaging 
performed resulting from an ED referral, had to be reported  within 2  hours (ideally under 1  hour).  A 
combination  of  staffing,  duty  obligations  and  key  performance  indicators  resulted  in  a  poor  physical 
environment, and created many interruptions to the Radiologists interpreting and reporting on, what were 
sometimes very complex presentations, similar to that of Mr Moreton’s. 

Since  Mr  Moreton’s  admission,  the  Trust  has  increased  its  staffing  within  working  hours  (Monday  to 
Friday  09.00  to  17.00),  to  3  to  4  Radiologists  on  duty  per  shift,  with  1  Radiologist  responsible  for 
managing the duty line.  A more flexible approach to what can and cannot be reported within an allotted 
two-hour acute reporting block has also been adopted.  This frees up 2 to 3 Radiologists to focus on 
interpreting  and  reporting.    There  is  less  requirement  for  referrers  to  discuss  their  referrals  with  a 
Radiologist, demand from the duty line has lessened and the timescales by which the imaging is to be 
reported on.  These improvements have therefore provided a safer environment for the Radiologists to 
operate within.   

Radiology is provided by Everlight (external teleradiology service) out of hours (Monday to Friday 20.00 
to 09.00 and 19.00 to 09.00 on weekends).  During on-call arrangements (Monday to Friday 17.00 to 
20.00 and weekends 09.00 to 19.00), 1 Trust Radiologist is on shift, but there is provision in place for 
5 

 
 
 
 
 
 
 
 
 Trust  Radiologists  to  seek  support  from  Everlight  if  there  is  increased  demand/pressure  within  the 
Radiology Department.  The newer referral process outlined above is replicated out of hours and during 
on-call. 

Operationally  NHS  Radiology  Departments  cannot  guarantee  that  Radiologists  who  may  have  been 
involved  in  the  justification  of  a  scan,  be  the  Radiologist  who  interprets  and  reports  on  it.    With  the 
reduction in the telephone duty system and the introduction of Radiographers being able to justify certain 
CT images, it is likely most referrals will be limited to what is documented on ICE.  With the intended 
improvements to the quality of referrals being made by the educational programme and introduction of 
the  differential  diagnosis  box  within  the  ICE  system  and  the  IBD  SOP,  that  the  overall  quality  of 
information  gleaned  within  the  referral  process  will  improve,  and  the  involvement  of  more  than  1 
Radiologist  will  not  give  rise  to  errors  within  the  arrangement,  particularly  now  that  the  reporting 
environment is more productive.   

The  Trust  however  recognises  that  there  may  be  occasions  where  referrers  and  the  Radiology 
Department need to discuss a referral.  As aforementioned, such discussions were not documented or 
recorded  at  the  time  of  Mr  Moreton’s  admission.    The  Radiology  Department  utilises  RIS  (radiology 
information system) which has the ability to document any relevant information, and each Radiologist 
has  access  to  the  system.    Following  Mr  Moreton’s  death,  Radiology  staff  have  been  reminded  of 
situations where it might be appropriate to record information on RIS, particularly discussions during the 
justification process, which could be reviewed by the Reporting Radiologist, if the imaging was justified 
by another Radiologist. 

Concerns 4, 7 and 8 

Over the course of the inquest evidence was heard on a number of issues where information passed to 
and from clinicians involved in Mr Moreton’s care was inaccurate and misleading.  

Clinicians in Newcastle when asked for advice were under the impression treatment was working as it 
was mentioned his discharge from hospital was contemplated and this was not the case. 

Overall I am concerned about the poor and misleading communications between clinicians, departments 
and Hospital Trusts on matters of vital importance to patient care. 

The inquest heard that the Trust’s treating clinical team were looking for signs of a gradual improvement 
in Mr Moreton whilst on biologic medicines.  Mr Moreton’s condition fluctuated but there was no overall 
improvement.  The inquest further heard that in line with British Society of Gastroenterology guidelines, 
by days 13 and 15 of Mr Moreton’s admission, alternative treatment should have been considered, as 
the absence of improvement would have been as equally concerning as Mr Moreton deteriorating.  The 
Trust has therefore also considered whether the Trust’s Stop the Line SOP, which was a live document 
at the time of Mr Moreton’s admission, could have been utilised during his care.  The SOP sets out that 
‘Stop the Line’ is a patient safety alert system where any clinical activity ceases, for staff to question or 
seek clarity on the effectiveness of the activity, and to prevent harm to the patient from occurring.  The 
spirit of the SOP could have been utilised to reassess Mr Moreton’s care and consider an alternative 
approach  in  view  of  the  absence  of  improvement.    The  Trust’s  daily  ward  round  documentation 
incorporates  a  review  of  a  patient’s  progress  against  the  plan,  and  the  need  to  confirm  or  revise 
escalation plans, if there a change is indicated.  However, the Trust has considered ‘Stop the Line’ could 
be more prescriptive within the ward round templates to ensure the clinical team recognise where this 
SOP applies and utilise it.  The ward round documentation will therefore be updated to reflect this. 

In Trust policies and SOPs where handover and referrals feature, it is set out that staff are to utilise the 
standard  communication  structure/format  of:  Situation  Background  Assessment  Recommendation 
(SBAR).  An SBAR internal referral form has been in existence within the Trust for a number of years. 
NHS  England  sets  out  that  the  SBAR  tool  is  one  of  the  most  well  used,  effective  improvement 
methodologies to escalate a clinical problem that requires attention, or to facilitate efficient handover of 
patients  between  clinicians  or  clinical  teams.    The  tool  can  be  used  in  urgent  or  non-urgent 

6 

 
 
 
 
 
 
 
 
 
 communications, verbal or written exchanges, in escalation and handover and in clinical and managerial 
environments.  An SBAR communication should convey the following: 

  Situation – who the referrer is, which patient the referral relates to, and what the concern is. 
  Background – what the reason is for the patient’s admission, the patient’s medical history, and 

any relevant clinical details. 

  Assessment  –  what  investigations  have  been  undertaken  and  what  the  referrer’s  clinical 

impression or concerns might be.   

  Recommendation  –  what  is  being  requested  from  the  communication  and  the  timescales 

involved.   

Whilst staff are expected to utilise SBAR within handover and referrals, and is clearly referenced within 
various policies and SOPs, it would appear that this system has lost momentum within the Trust.  SBAR 
is therefore being relaunched throughout the Trust and meetings are ongoing to determine how best to 
achieve  this.    Clinicians  will  be  expected  to  utilise  SBAR  in  any escalation  of  a  clinical  problem  that 
requires attention, or to facilitate efficient handover, both internally and externally.   

Where contact is made to a clinician or clinical team for advice via telephone utilising SBAR and advice 
is given over the telephone, the referrer will be required to email the advisor detailing the discussion, 
and then place a copy of this in the patient’s records.  This provides the advisor with the ability to clarify 
their advice if there has been any misinterpretation, and ensures the advisor is provided with a copy of 
the discussion, as they may not have access to the patient’s records.  This requirement will be rolled out 
within the SBAR relaunch.  

The  IBD  SOP  mandates  joint  care  between  general  surgery  and  gastroenterology.    Any  clinician 
managing  the  care  of  a  patient  presenting  with  IBD  will  be  required  to  refer  to  and  follow  the  SOP, 
ensuring  that  necessary  referrals  to  general  surgery  and  gastroenterology  are  made.    If  a  referral  is 
made to either general surgery or gastroenterology, it is the responsibility of the service referred to, to 
ensure the involvement of the other service.   

The Trust now holds  joint biweekly IBD multidisciplinary team meetings  (MDTs) between the internal 
general surgery and gastroenterology teams.  A triweekly joint specialist IBD MDT between the Trust 
and Newcastle upon Tyne Hospitals NHS Foundation Trust has also been established since February 
2023.   An MDT, made up of a variety of specialists with an interest in IBD or gastroenterology, approach 
to  the  management  of a  patient’s  IBD,  is  recommended  to  provide  optimised  and  personalised  care, 
based on available professional expertise, infrastructure and funding, and helps to prevent errors in the 
delivery  of  care  and  avoid  related  harm  to  patients.    The  timing  of  MDT  meetings  happen  on  the 
aforementioned  frequencies  to  ensure  decision-making  is  not  delayed,  however,  such  discussions 
largely  relate  to  complex,  chronic  IBD  patients.    Acute  or  emergency  care  decisions  cannot  not  be 
delayed  for  timetabled  MDTs,  but  should  happen  separately  between  relevant  specialists.    The 
introduction of the MDTs has improved  working relationships and communication between the teams 
and Trusts, to ensure early referrals for specialist input in the management of a patient’s care is sought, 
for patients who are acutely unwell and/or where urgent advice is required.  Had the MDTs been in place 
during  Mr  Moreton’s  admission,  he  likely  would  have  been  listed  for  discussion  in  both  MDTs  and 
professional relationships would have been established to seek earlier input from surgical colleagues 
and specialists in Newcastle. 

The Trust has also made changes to its on-call system during the working week to ensure there is both 
a dedicated colorectal and an upper GI surgeon of the week.  While the conditions that both surgeons 
treat may sometimes overlap, it is a colorectal surgeon that specialises in the surgical management of 
IBD patients, and previous on-call arrangements meant that there was not always a dedicated colorectal 
surgeon available.   

Concern 6 

It was assumed Mr Moreton would be referred for a surgical opinion by ED department clinicians when 
in fact none took place. 

7 

 
 
 
 
 
 
 
 
 
 The IBD SOP will ensure the involvement of both the general surgery and gastroenterology teams via 
referral from any service managing a patient with presenting IBD. 

Once  again,  thank  you  for  bringing  your  concerns  to  my  attention.    I  hope  that  the  above  provides 
assurance  to  you,  Mr  Moreton’s  family,  and  the  public,  that  the  Trust  has  taken  them  seriously  and 
appropriate action is being taken to prevent any similar future deaths.   

I appreciate not all of the actions are yet implemented and I would be happy to provide updates on these 
in  the  future,  should  you  require  this.    Please  also  let  me  know  if  you  require  clarity  on  any  of  the 
responses I have provided above. 

Yours sincerely 

Chief Executive 

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