Geoffrey Moyse
19 Feb 2016 · Coroner Veronica Hamilton-Deeley · Brighton and Hove
The coroner's concerns
1. delayed referral to appropriate surgeon
“Please see the attached letter dated the 19"" December 2014 which explains the system which was put in place by the CCG”
2. lack of direct communication between consultant and clinic
“why did the Consultant [name redacted] not contact the colo- rectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015”
3. inadequate initial referral pathway
“Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19"" December 2015?”
4. failure to transmit histology report to relevant clinic
“Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve”
5. fragmented healthcare processes
“It just seems to me that this system broke down because these processes seem to work without any reference to a joined up approach and the person who suffers is the patient”
6. need for systemic review to prevent future delays
“| would like to see a complete review of this process and | am sure that Mrs [name redacted] would be happy, suitably anonymised, if Mr [name redacted] case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own”
Responses
G-moyse-Response_Redacted.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action
“We have reviewed our involvement in Mr [name redacted] care and have outlined below the actions Brighton and Hove Integrated Care Service propose to take”
Moyse-Response.pdf ↗· Brighton and Sussex University Hospitals NHS Trust
Stated action · June 2016
“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 [name redacted], 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”