We report the findings of our multidisciplinary, polyperspective, collaborative quality improvement project.

Infants with bile-stained vomit require an upper gastrointestinal (GI) contrast and review by a paediatric surgeon to exclude a midgut volvulus due to malrotation. Surgical and radiological findings of this potentially fatal condition1 are shown in figure 1. At our institution, a patient referred from a local neonatal unit (LNU) with bilious vomiting would be reviewed by the Southampton Oxford Neonatal Transport team (SONeT). SONeT would stabilise the baby and transfer to a surgical cot in the John Radcliffe Newborn Care Unit (NNU) where tertiary services are located. The baby would be prepared for contrast study; accompanied by two porters, a registrar and nurse to the …