Akhona Moyo

I am Hassan SHAH, Assistant Coroner for the coroner area of Northamptonshire

On 20 December 2022 I commenced an investigation into the death of Akhona MOYO aged 4. The investigation concluded at the end of the inquest on 27 January 2026. The conclusion of the inquest was that: Akhona Moyo died 26 November 2022 at Queens Medical Centre, Nottingham as a result of a brain tumour. Had he been admitted to hospital on 23rd November 2022, scanned earlier in the day on 24 November 2022 and received earlier intervention directed at reducing intracranial pressure, he probably would have survived.

Akhona Moyo died 26 November 2022 at Queens Medical Centre, Nottingham as a result of a brain tumour. Had he been admitted to hospital on 23rd November 2022, scanned earlier in the day on 24 November 2022 and received earlier intervention directed at reducing intracranial pressure, he probably would have survived. The medical cause of death was: 1a. Acute obstructive hydrocephalus 1b. Posterior fossa ependymoma A narrative conclusion was given as above

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc. At Northampton General Hospital, a new electronic system known as “Nerve Centre” contains only hospital notes. Hospital doctors also have access to the “Northamptonshire Care Record” which contains basic lists of GP visits and medication, but no detailed entries. All the doctors that gave evidence to the Inquest stated that access to primary care records would undoubtedly assist them in delivering better patient treatment and care. It was felt that access to such information was particularly important in cases such as the present when a patient is autistic and non-verbal. There may be a multitude of other reasons why a patient or their family may not be able to relay to doctors a full and accurate medical history. Access may also enable doctors to have a more global view of a patient’s medical condition rather than, as it was put at Inquest, “working in silos”.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.