Gareth Tatchell

1. 1. delayed cancer diagnosis and treatment

   “During the course of the inquest it transpired that the Suspected Cancer Pathway introduced for the whole of Wales in 2019 required a suspected cancer to be diagnosed and staged within 31 calendar days of the date of referral and for treatment to commence within 62 calendar days from the date of referral. In this case the diagnostic and staging phase was completed in 97 days from the date of referral and treatment commenced within 144 days of the date of treatment. The result of that delay was that it made the carcinoma more difficult to treat in that it would not have had the extracapsular spread or the encasement of the carotid that was witnessed at the end of August and which was not present around the end of June when treatment ought to have taken place. Had the timescales had been complied with then treatment would have been administered before extracapsular spread had occurred. Evidence was received from the treating consultant that this contributed towards [the deceased]'s death.”

2. 2. delayed staging scans

   “I am concerned that delays in undertaking staging scans are allowing such cancers to progress to the point that they are irresectable, resulting in poor prognosis for patients and reducing survivability rates and life expectancy and there is a risk that future deaths will occur unless action is taken”

3. 3. improved theatre capacity

   “Evidence was heard that since this incident there had been an improvement in theatre capacity with additional theatre sessions having been allocated to oral and maxillofacial surgery, and an additional Consultant [name redacted] Surgeon has been appointed to undertake both surgery and outpatient appointments”

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