Geoffrey John MOYSE · Prevention of Future Deaths report

On 17th February 2016 I commenced an investigation into the death of Geoffrey John MOYSE. The investigation concluded at the end of the inquest on 17th February 2016. The conclusion of the inquest was Medical Misadventure.

See Record of Inquest

(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.

Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.

It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that.

There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?

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?

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 19th December 2015? If he had, perhaps the whole system would have worked.

One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.

It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.

In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s 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.