“Evidence was heard that at the time of the inquest radiologists do not have access to…”

The coroner’s concerns

- 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 comptemplated - 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0352

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0