Sara Grinnell
17 Sept 2024 · Coroner Patricia Morgan · South Wales Central
The coroner's concerns
1. delay in contacting patient for urgent gynaecology appointment
“Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment”
2. reliance on written correspondence only
“The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P.”
3. failure to escalate urgency of referral
“When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact”
4. delay in cancer diagnosis
“As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis”