A coroner has slammed the NHS following the tragic demise of a 52 12 months outdated lady from most cancers who waited two years for her prognosis as a result of she by no means acquired hospital letters.
Sara Grinnell endured a 24 month wait earlier than her illness was detected as a result of lacking letters and ‘delays in investigating her signs’, an inquest heard.
By the point she was lastly seen, it was too late and her solely accessible therapy was end-of-life care.
South Wales coroner Patricia Morgan has now written to the well being service warning there had been a ‘missed alternative’ and ‘intensive delays’.
The inquest heard Mrs Grinnell’s first pressing referral got here in June 2019 following an ultrasound for heavy intervals.
The Princess of Wales Hospital in Brigend the place Mrs Grinnell handed away in April 2022
Nevertheless, she by no means acquired the letters and needed to be referred three extra occasions earlier than being identified with endometrial most cancers in June 2021, the coroner mentioned.
Her deliberate hysterectomy in September 2021 was postponed due to ‘inadequate theatre time’ and he or she handed away in April 2022 on the Princess of Wales Hospital in Bridgend, Wales.
In a Prevention of Future Deaths report, the coroner mentioned: ‘In June 2021, Mrs Grinnell was identified with endometrial most cancers.
‘A deliberate hysterectomy on 10 September 2021 was postponed as a consequence of inadequate theatre time.
‘Her therapy choices have been restricted to palliative.’
Ms Morgan advised the Cwm Taf Morgannwg College Well being Board – which manages the hospital – warning them that there was a ‘missed alternative’ to extend the urgency of their contact with Mrs Grinnell.
She was despatched two letters after her first referral which she didn’t obtain however there was no ‘additional consideration’ of contacting her by way of telephone or e mail.
The coroner mentioned there was additionally a ‘lack of regard’ for the earlier referrals when Mrs Grinnell was re-referred as a consequence of her ‘ongoing and worsening signs’.
The inquest heard that Mrs Grinnell had suffered ‘extreme vaginal bleeding’ since 2015 and had a cervical polyp eliminated in 2018 however her heavy intervals continued which is why she was referred to the gynaecology division.
It was not till her fourth referral in Could 2021 that she was positioned beneath the pressing suspected most cancers pathway.
‘The conclusion of the inquest was Mrs Grinnell died on account of the development of endometrial most cancers.
‘There have been delays in investigating her signs which can have recognized potential therapy choices at an earlier stage,’ Ms Morgan mentioned.
In a Prevention of Future Deaths Report Ms Morgan was extremely essential of the Well being Board and warned there was a ‘threat that future deaths will happen’ except they take motion.
‘Following an ultrasound scan carried out in June 2019, and pressing referral to the gynaecology division, there was an intensive delay in extra of twenty-two weeks in making an attempt to contact the affected person with an pressing appointment,’ she wrote.
‘The technique of contacting the affected person for an pressing gynaecology appointment was by way of written correspondence with out additional consideration of different means by way of phone, e mail, or by way of GP.
‘When the GP re-referred the affected person to the gynaecology division as a consequence of ongoing and worsening signs there was an absence of regard to earlier referrals and the intensive delay that had already occurred and a missed alternative to escalate the urgency of contact.
‘As a consequence this resulted in a major delay of 24 months between the pressing referral to gynaecology division and eventual prognosis.’
Ms Morgan added Cwm Taf Morgannwg College Well being Board has an obligation to reply by twelfth November.
