Peter Smith
5 Feb 2020 · Coroner John Ellery · Shropshire, Telford & Wrekin
The coroner's concerns
1. delay in diagnosis and treatment of adenocarcinoma
“There was significant delay in the diagnosis and treatment of Mr [name redacted] adenocarcinoma which contributed to his death on the 4th March 2019.”
2. consecutive scheduling of tests and appointments
“Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible.”
3. lack of concurrent testing and advance planning
“Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did.”
4. fragmented care across trusts
“Although separate Trusts they were effectively treating Mr [name redacted] adenocarcinoma as one.”