William Hare
23 Dec 2024 · Coroner Rebecca Mundy · Essex
The coroner's concerns
1. delay in diagnosis
“overall delay in reaching any diagnosis in Bill's case and, therefore, any treatment plan being implemented”
2. delay in first biopsy
“delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days”
3. delay in appointment after MDT referral
“delay from the MDT referring the case to the Consultant, to an appointment taking place in May 2023”
4. delay in MDT review of CT results
“additional delay between the further CT scan ordered by the Consultant, which took place on 5 June, and the MDT which considered the results and treatment plan on 29 August”
5. delay in surgery due to HBA1c assessment
“further delay occurred from 4 September, as Bill had been assessed as unfit for surgery due to his HBA1c reading”
6. disjointed inter‑hospital coordination and transport failures
“delays in progressing his treatment due to the disjointed nature of the inter‐relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer”