Coroner criticises NHS over cancer death of 52-year-old woman who waited two years for diagnosis because she never received hospital letters about her ultrasound results

A coroner has sharply criticised the British National Health Service (NHS) after a 52-year-old woman tragically died of cancer after having to wait two years for her diagnosis because she never received letters from the hospital.

According to an investigation, Sara Grinnell had to wait 24 months for her illness to be diagnosed due to missing letters and “delays in investigating her symptoms.”

When she was finally examined, it was too late and the only treatment available was end-of-life care.

South Wales Coroner Patricia Morgan has now warned in a letter to the health authority that there has been a “missed opportunity” and “significant delays”.

The investigation found that Ms Grinnell's first urgent referral was in June 2019 following an ultrasound scan for heavy periods.

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

Her hysterectomy, scheduled for September 2021, was postponed due to “insufficient operating time” and she died in April 2022 at the Princess of Wales Hospital in Bridgend, Wales.

In a report to prevent future deaths, the coroner said: “In June 2021, Mrs Grinnell was diagnosed with uterine cancer.”

“A planned hysterectomy on September 10, 2021 was postponed due to insufficient operating room time.”

“Their treatment options were limited to palliative measures.”

Ms Morgan told Cwm Taf Morgannwg University Health Board, which manages the hospital, that this was a “missed opportunity” to increase urgency in contacting Ms Grinnell.

After her first transfer, she received two letters, which she did not receive. However, contact by phone or email was “not further considered”.

The coroner said previous referrals had also been “not adequately taken into account” when Ms Grinnell was referred again due to her “persistent and worsening symptoms”.

On investigation, it was found that Ms Grinnell had been suffering from “excessive vaginal bleeding” since 2015 and had undergone a cervical polyp removal in 2018. However, her periods remained heavy, so she was referred to the gynaecology department.

It was not until her fourth referral in May 2021 that she was admitted for emergency treatment for suspected cancer.

“The result of the investigation was that Mrs Grinnell died as a result of progressive uterine cancer.”

“There were delays in investigating her symptoms, which may have uncovered potential treatment options sooner,” Ms Morgan said.

In a report on preventing future deaths, Ms Morgan sharply criticized the health authority, warning that if it did not intervene, “there is a risk that deaths will occur in the future.”

“Following an ultrasound scan performed in June 2019 and an urgent referral to the gynecology department, there was a significant delay of over 22 weeks in attempts to reach the patient for an urgent appointment,” she wrote.

“The patient was contacted via correspondence regarding an urgent appointment with the gynecologist, without considering other options such as telephone, email or the family doctor.”

“When the GP re-referred the patient to the gynaecology department due to persistent and worsening symptoms, previous referrals were not adequately considered. Significant delays had already occurred and an opportunity to increase the urgency of contact had been missed.”

“This resulted in a significant delay of 24 months between urgent referral to the gynecology department and final diagnosis.”

Ms Morgan added that the Cwm Taf Morgannwg University Health Board was required to respond by November 12.