Sara Grinnell endured delay before disease was detected because she never received ultrasound scan results from hospital

A woman died from cancer after waiting two years for the NHS to call or email her with her ultrasound scan results, a coroner has ruled.

Despite an urgent referral being made, Sara Grinnell endured a 24-month wait before her disease was detected because she never received the hospital’s letters, an inquest heard.

By the time she was finally seen, it was too late and her only available treatment was end-of-life care.

South Wales coroner Patricia Morgan has now written to the NHS criticising the health service for its “missed opportunity” and “extensive delays” in Mrs Grinnell’s tragic case.

The inquest heard that her first urgent referral came in June 2019 following an ultrasound for heavy periods.

However, she never received the letters and had to be referred three more times before being diagnosed with endometrial cancer in June 2021, the coroner said.

Her planned hysterectomy in September 2021 was postponed because of “insufficient theatre time” and she died in April 2022 at the Princess of Wales Hospital in Bridgend.

‘Missed opportunity’

In a prevention of future deaths report, the coroner said: “In June 2021, Mrs Grinnell was diagnosed with endometrial cancer.

“A planned hysterectomy on Sept 10 2021 was postponed due to insufficient theatre time. Her treatment options were limited to palliative.”

Ms Morgan told Cwm Taf Morgannwg University Health Board, which manages the hospital, that there was a “missed opportunity” to increase the urgency of their contact with Mrs Grinnell.

She was sent two letters after her first referral that she did not receive, but there was no “further consideration” of contacting her via phone or email.

The coroner said that there was also a “lack of regard” for the previous referrals when Mrs Grinnell was re-referred because of her “ongoing and worsening symptoms”.

The inquest heard that Mrs Grinnell had suffered “excessive vaginal bleeding” since 2015 and had a cervical polyp removed in 2018, but her heavy periods continued, leading to her being referred to the gynaecology department.

It was not until her fourth referral in May 2021 that she was placed under the urgent suspected cancer p athway.

“The conclusion of the inquest was Mrs Grinnell died as a result of the progression of endometrial cancer.

“There were delays in investigating her symptoms which may have identified potential treatment options at an earlier stage,” Ms Morgan said.

‘Excessive delay’

In her report, Ms Morgan was highly critical of the health board and warned there was a “risk that future deaths will occur” unless they take action.

“Following an ultrasound scan performed in June 2019, and urgent referral to the gynaecology department, there was an extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment,” she wrote.

“The means of contacting the patient for an urgent gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via GP.

“When the GP re-referred the patient to the gynaecology department due to ongoing and worsening symptoms there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.

“As a consequence this resulted in a significant delay of 24 months between the urgent referral to the gynaecology department and eventual diagnosis.”

Ms Morgan added that Cwm Taf Morgannwg University Health Board has a duty to respond by Nov 12.