A patient was neglected before his death in a North East hospital trust, after "poor and misleading" communications between hospital trusts.
Brian Moreton died in May 2022, at Freeman Hospital in Newcastle. He had been transferred into the hospital a month previously, from Cumberland Infirmary, nearer his home in Cumbria.
Newcastle Coroner James Thompson criticised the communication between North Cumbria Integrated Care NHS Foundation Trust (NCIC) and Newcastle Hospitals Trust.
But NCIC, the hospital trust most heavily criticised by the coroner, said that they have already made changes to the way that they communicate with other trusts, and look after patients with complex bowel diseases.
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Mr Moreton was admitted to the Cumberland Infirmary on March 2 last year with diarrhoea, recurring fever and a distended abdomen. A toxic megacolon was in a CT scan when he was admitted, but was not reported to those treating him.
Healthcare staff prescribed a high dose of immunosuppressant drugs but saw no improvement in his state. A month after being admitted to Cumberland Infirmary, he was transferred to the Freeman Hospital in Newcastle.
Doctors in Newcastle discovered that his bowel had perforated and operated but he remained "seriously ill", developing infections due to his immunosuppressed state. Mr Moreton died from these infections on May 6, 2022.
Now, the corner has raised concerns about how the two trusts had communicated, as well as internal communication.
"Inaccurate and misleading" information had been passed between clinicians whilst they were caring for Mr Moreton.
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At the inquest into the man's death, it was heard that radiologists do not have access to patients' medical notes and base their reporting on a summary document submitted by the department requiring imaging.
For Mr Moreton, this summary was wrong - excluding his fever. The internal communication system was found to be prone to error, with the clinicians being briefed on patients often not being the ones carrying out imaging.
Doctors in Newcastle were under the impression that treatment in Cumberland had been working, as "his discharge from hospital was contemplated."
In a report, the coroner wrote: "Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care," but "this was not the case."
He added: "In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action."
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A spokesperson for NCIC said: "We offer our sincere condolences to Mrs Moreton and her family.
"We have already made changes as a result of learning from Mr Moreton’s care including the way we communicate with other trusts involved with a patient who has complex bowel disease.
"We have listened to what the Coroner said and we will be making further changes and improvements as a result."
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