Woman Dies of Cancer After Two-Year NHS Communication Failure

In a tragic case highlighting systemic issues within the National Health Service (NHS), a woman lost her life to endometrial cancer following a two-year delay in diagnosis. The delay was attributed to communication failures within the healthcare system, as revealed by a recent coroner's inquest.

Sara Grinnell's journey through the healthcare system began in June 2019 with an urgent referral for an ultrasound scan due to heavy menstrual periods. Despite this initial step, Grinnell never received the hospital's follow-up communications, leading to a series of missed opportunities for early diagnosis and treatment.

"There was a missed opportunity to increase the urgency of their contact with Mrs Grinnell."

The coroner's report unveiled a distressing timeline of events. Grinnell had been experiencing excessive vaginal bleeding since 2015, a common symptom that affects approximately one in five women of reproductive age. In 2018, she underwent a cervical polyp removal, a procedure performed on 2-5% of women, typically for benign growths. However, her symptoms persisted, prompting the initial referral in 2019.

Over the next two years, Grinnell was referred three more times before finally receiving a diagnosis of endometrial cancer in June 2021. This extensive delay is particularly alarming considering that early detection of endometrial cancer can lead to a five-year survival rate exceeding 95%. The average age of diagnosis for this type of cancer is 60 years old, and it is the most common gynecological cancer in developed countries.

The NHS Constitution guarantees patients the right to access services within maximum waiting times, including a two-week maximum wait for suspected cancer cases from GP referral to first consultant appointment. In Wales, where this case occurred, the urgent suspected cancer pathway aims to ensure diagnosis within 62 days. Tragically, Grinnell's case far exceeded these timeframes.

A planned hysterectomy, the most common treatment for endometrial cancer, was scheduled for September 10, 2021. However, it was postponed due to "insufficient theatre time." By this point, Grinnell's treatment options were limited to palliative care. She passed away in April 2022 at the Princess of Wales Hospital in Bridgend, an institution opened in 1985.

Coroner Patricia Morgan issued a prevention of future deaths report, criticizing the Cwm Taf Morgannwg University Health Board for its handling of the case. The health board, formed in 2019 through a merger of previous organizations, oversees NHS services in the region. Morgan highlighted the "lack of regard" for previous referrals and the failure to explore alternative methods of contacting the patient, such as phone or email.

The NHS, founded in 1948 and one of the world's largest publicly funded healthcare systems, has been working to implement electronic health records to improve communication and patient care. However, this case underscores the ongoing challenges in effectively utilizing such systems.

The health board has been given until November 12, 2024, to respond to the coroner's report. This case serves as a stark reminder of the critical importance of efficient communication and follow-up procedures in healthcare systems, where delays can have life-altering consequences.