Cancer patient's treatment was delayed - coroner

A coroner found there were "missed opportunities" to treat a 38-year-old woman with cancer.

Carla Smith, 38, who died on 7 June 2023, had metastatic endometrial cancer which had been rapidly progressing.

In a a prevention of future deaths report, the area coroner for Norfolk, Samantha Goward, said there had been "significant delays" getting laboratory results and "lengthy waiting lists - even for urgent referrals".

Rebecca Martin, medical director at the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, said it had carried out an investigation into Ms Smith's care and had learnt from the coroner's findings.

The report said Ms Smith went to her GP surgery in July 2022 for an ultrasound scan which showed she had a thickened endometrium, which should have led to a referral to the gynaecology team.

An urgent referral was made with an anticipated wait of four to six weeks, which should have been "upgraded" to a two-week wait.

On 31 January 2023 when she was next seen, a biopsy was taken and was wrongly marked as "routine", the report said.

Ms Smith went to hospital that April with "ongoing heavy bleeding". A CT scan showed signs of advanced endometrial malignancy with "disseminated metastasis".

This prompted a report on January biopsy, said the report, which showed "grade one" womb cancer.

"After a further biopsy and investigations... it was felt that Carla had stage four cancer," stated the report.

It added: "While an initial plan was made for surgery, due to the unusually aggressive nature of the cancer, Carla rapidly deteriorated... and palliative care commenced."

The area coroner's report highlighted matters of concern.

They included how one hospital had a gynaecology referral wait time of18 weeks, and another had a wait of 30 weeks.

The report said in this wait time, patients could "significantly deteriorate" and could miss out on treatment options.

It said patients could be left waiting for a long time without their case being reviewed or a different referral being made.

Rebecca Martin, medical director at the Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, said the care Ms Smith received at the trust "fell below the standards".

She said: "We are committed to learning all that we can to prevent this from happening again and therefore carried out a full investigation.

"We have learnt from these findings which have highlighted the importance of correctly triaging urgent referrals and samples and taken action to address the findings."

The Department of Health and Social Care has 56 days to respond to the coroner's report.

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