PFD report

Brian David MORETON · Prevention of Future Deaths report

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Issued 25 Sep 2023•Newcastle and North Tyneside

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians
    Part of recurring concern: Failure to provide sufficient clinical information for diagnostic imaging interpretationPart of recurring concern: Unreliable coordination of radiology services between healthcare teams
  2. Failure to communicate accurate clinically important information between clinicians and departments
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
  3. Lack of radiologist access to patients’ medical notes during imaging assessment
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Participate in a regular Inflammatory Bowel Disease multidisciplinary team meeting at Newcastle to improve communication and advice between the Trusts.

    Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
  2. Action

    Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2023.
  3. Action

    Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.

    Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Radiology triage arrangements failing to ensure reliable transfer of referral information to imaging clinicians

Wider context from the report

“- 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 call 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 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. - 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. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - 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 contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient clinical information for diagnostic imaging interpretation; Unreliable coordination of radiology services between healthcare teams.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to communicate accurate clinically important information between clinicians and departments

Wider context from the report

“- 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 call 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 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. - 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. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - 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 contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of patient-care information between clinical staff; Unreliable inter-agency information sharing for coordinated care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of radiologist access to patients’ medical notes during imaging assessment

Wider context from the report

“- 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 call 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 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. - 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. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - 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 contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete required referral for surgical opinion

Wider context from the report

“- 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 call 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 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. - 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. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - 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 contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

Is this part of a recurring concern?

Yes — Unreliable and delayed surgical referral and review.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information

Wider context from the report

“- 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 call 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 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. - 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. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - 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 contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to provide sufficient clinical information for diagnostic imaging interpretation.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Participate in a regular Inflammatory Bowel Disease multidisciplinary team meeting at Newcastle to improve communication and advice between the Trusts.

Verbatim wording from the response

“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.”

Source location

Response from DAC Beachcroft
Page 1 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.

Verbatim wording from the response

“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:”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and ratify an inflammatory bowel disease SOP covering acute severe colitis red flags, toxic megacolon and specialist referrals.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.

Verbatim wording from the response

“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 within 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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement digital patient-record access by maintaining Radiology access to Clinica Portal and WebV and extending access to Symphony Paperlite and the new EPR.

Verbatim wording from the response

“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 Clinica 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 which records should be accessed in line with the Royal College of Radiologists.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Radiology departments cannot guarantee that the radiologist justifying imaging will also interpret and report it.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Radiologists could not routinely leave the department to review referring-department records because operational pressures made this infeasible.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Involvement of different radiologists in imaging justification and reporting is not expected to cause errors under the improved referral and reporting arrangements.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 5 October 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Implement the Trust-wide inpatient EPR to replace paper records and digitise legacy case notes.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2023.
  2. 2

    Change weekday on-call arrangements to provide dedicated colorectal and upper gastrointestinal surgeons of the week.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
  3. 3

    Update ward-round documentation to make Stop the Line applicability more prescriptive when patient progress fails to improve.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 October 2023.
  4. 4

    Increase weekday Radiology staffing to three or four Radiologists per shift, with one dedicated to the duty line.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
  5. 5

    Adopt flexible acute-reporting arrangements to free Radiologists for image interpretation and reporting.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the Trust-wide inpatient EPR to replace paper records and digitise legacy case notes.

Verbatim wording from the response

“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 EDS across the Trust’s acute hospital sites and the Urgent Treatment Centres. Patient information in EDS is now recorded directly onto Symphony, removing any paper records and the need for any specialist 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 remove some inpatient and outpatient paper records and legacy paper case notes will be digitised into a digital repository.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Change weekday on-call arrangements to provide dedicated colorectal and upper gastrointestinal surgeons of the week.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 7 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update ward-round documentation to make Stop the Line applicability more prescriptive when patient progress fails to improve.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 6 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase weekday Radiology staffing to three or four Radiologists per shift, with one dedicated to the duty line.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 5 October 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Adopt flexible acute-reporting arrangements to free Radiologists for image interpretation and reporting.

Verbatim wording from the response

“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.”

Source location

Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 5 October 2023

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026