Recurring concern

Unreliable coordination of cancer diagnosis and treatment

First to latest report 11 Feb 2016 — 4 Jul 2024

Reports that mention this concern: 3
Times this concern has been raised: 3
Stated actions linked to this concern: 14

What this concern includes

Includes failures in coordinating the end-to-end cancer diagnosis and treatment pathway, including communication between responsible teams, sequencing or concurrency of investigations, reporting, referral, treatment planning and progression to treatment where these directly delay or compromise cancer care.

What is not included

Excludes generic communication failures with no cancer diagnosis or treatment context.
Excludes isolated failures in cancer screening, cancer-red-flag recognition or two-week-wait referral where pathway coordination is not the shared unsafe condition; those belong to narrower named concerns.
Excludes delays caused solely by a shortage of scanning, pathology or treatment capacity when no coordination failure is identified.
Excludes clinical treatment or diagnostic decisions made after the cancer pathway has been reliably coordinated.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Barking, Havering and Redbridge University Hospitals NHS Trust1

Department of Health and Social Care1

Medicines and Healthcare products Regulatory Agency1

the Shrewsbury and Telford Hospital NHS Trust1

University Hospitals of North Midlands NHS Trust1

University Hospitals Sussex NHS Foundation Trust1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

4 Jul2024
East London
Concerns raised1
1. Poor organisation of cancer diagnosis and treatment
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Barking, Havering and Redbridge University Hospitals NHS Trust
Department of Health and Social Care
Medicines and Healthcare products Regulatory Agency
Stated actions 3
1. Department of Health and Social Care
  Continue working with NHS England and local systems to reduce cancer waiting times and support earlier-stage diagnosis.
2. Barking, Havering and Redbridge University Hospitals NHS Trust
  Require responsible consultant approval before removing or deferring any cancer patient from the Patient Tracker List.
3. Barking, Havering and Redbridge University Hospitals NHS Trust
  Restructure cancer administration pathways to provide new clinical oversight and streamlined communication.
Respondent positions 2
1. Medicines and Healthcare products Regulatory Agency
  Medical advice and guidance on medical practice or care quality fall outside the respondent’s remit.
  Outside remit
1. Department of Health and Social Care
  The Trust will respond separately to the concerns about care and processes.
  Redirects responsibility
AI-generated summary

David John Morris · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor organisation of cancer diagnosis and treatment
Wider context from the report
“1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust. ”
Source location
David John Morris · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue working with NHS England and local systems to reduce cancer waiting times and support earlier-stage diagnosis.

Verbatim wording from the response
“I wholeheartedly agree with you regarding the importance of organisations across the health system working together to ensure effective cancer diagnosis, and I regret that this did not occur in Mr Morris’ case. It is important to ensure that the issues you outlined in your report are not repeated. Thus, we will continue to work alongside NHSE and local systems to reduce waiting times and deliver on the NHS Long-Term Plan ambitions to diagnose 75% of cancers at stage 1 and 2 by 2028.”

Source location
2024-0360 - Response from DHSC
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require responsible consultant approval before removing or deferring any cancer patient from the Patient Tracker List.

Verbatim wording from the response
“Mr Morris’s treatment plan and diagnosis was delayed and complicated in part due to being downgraded in severity on the Patient Tracker List which led to a breakdown in communication between clinical pathways. With immediate effect, no patients that are currently on a Patient Tracker List for any cancer diagnosis can be removed or deferred without approval of the responsible consultant. This is to ensure that administrative processes have a clear oversight of a senior clinician who takes full responsibility for the treatment plan.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Restructure cancer administration pathways to provide new clinical oversight and streamlined communication.

Verbatim wording from the response
“In addition, a restructure of the cancer administration pathways is underway by the Speciality Manager for cancer performance; under the oversight of the Chief Operating Officer. This restructure is proposed to finish by 30 September 2024, with its implementation expected to result in new clinical oversight and streamlined communication.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Medical advice and guidance on medical practice or care quality fall outside the respondent’s remit.

Verbatim wording from the response
“The MHRA assesses the balance of risks and benefits of medical devices throughout their use in clinical practice through the collection of information and assessment of any potential risks, followed, when necessary, with communications and regulatory action to minimise those risks. The MHRA does not have a role in providing medical advice or guidance relating to medical practice or care quality and therefore cannot comment on those aspects of this case.”

Source location
2024-0360 - Response from MHRA
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Trust will respond separately to the concerns about care and processes.

Verbatim wording from the response
“I understand that the Barking, Havering & Redbridge University Trust will also be responding separately to your concerns and that the London region of NHS England is”

Source location
2024-0360 - Response from DHSC
Page 1 · response
Published 4 July 2024
Open published response
5 Feb2020
Shropshire, Telford and Wrekin
Concerns raised1
1. Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions
Linked responses

the Shrewsbury and Telford Hospital NHS Trust
University Hospitals of North Midlands NHS Trust
Stated actions 11
1. the Shrewsbury and Telford Hospital NHS Trust
  Update the standard operating procedure for referring suspected or confirmed lung cancer patients for surgical resection.
2. the Shrewsbury and Telford Hospital NHS Trust
  Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.
3. the Shrewsbury and Telford Hospital NHS Trust
  Implement and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.
1. the Shrewsbury and Telford Hospital NHS Trust
  Flag concerning abnormal chest X-rays to the Lung Cancer Team daily.
2. the Shrewsbury and Telford Hospital NHS Trust
  Triage CT results daily after abnormal chest X-rays raise possible lung cancer, alerting the Lung Cancer Team and responsible consultant.
3. the Shrewsbury and Telford Hospital NHS Trust
  Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.
4. the Shrewsbury and Telford Hospital NHS Trust
  Allow PET scans to be requested before multidisciplinary discussion, requiring discussion after the PET-CT result.
5. the Shrewsbury and Telford Hospital NHS Trust
  Increase surgical clinical capacity to prevent delays in clinic appointments.
6. the Shrewsbury and Telford Hospital NHS Trust
  Maintain coordinated lung cancer working arrangements with UHNM, including weekly thoracic surgical outpatient clinics and multidisciplinary team attendance.
7. the Shrewsbury and Telford Hospital NHS Trust
  Continue quality improvement work towards compliance with the National Optimal Lung Cancer Pathway.
8. University Hospitals of North Midlands NHS Trust
  Agree a standard operating procedure for referrals for surgical resection of proven or suspected lung cancer.
AI-generated summary

Peter Edward SMITH · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Peter Edward SMITH died on 4 March 2019 after relapsing on 20 February 2019. The report identified significant delay in the diagnosis and treatment of his adenocarcinoma, with tests, reports, appointments and discussions taking place consecutively so that surgery was no longer possible by the scheduled date.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions
Wider context from the report
“1. There was significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which contributed to his death on the 4th March 2019. 2. 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. 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. ”
Source location
Peter Edward SMITH · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the standard operating procedure for referring suspected or confirmed lung cancer patients for surgical resection.

Verbatim wording from the response
“The Trust and the teams involved recognise the delays in this case and have reviewed their pathways and processes. From November 2019, the Trust has updated their Standard Operating Procedure (SOP) which provides advice on the referral of patients for surgical resection of proven or suspected lung cancer to prevent delays. This covers the following areas:”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 1 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.

Verbatim wording from the response
“From November 2019, the Trust has streamlined the diagnostic pathway (enclosed at Appendix 2) for patients being investigated for potential lung cancer which involved collaboration with Clinical Commissioning Group’s regarding ‘direct to CT’ pathways and to the urgent ‘hot-reporting’ of chest x-”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 1 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.

Verbatim wording from the response
“Improvement work has been undertaken and evaluated with regards to developing diagnostic ‘bundles’ of tests to streamline investigations and agree which investigations are appropriate for specific patient groups, recognising that each investigation involves a potential delay, but that it is important to ensure that a patient is risk assessed appropriately prior to listing for surgical intervention.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Flag concerning abnormal chest X-rays to the Lung Cancer Team daily.

Verbatim wording from the response
“• Every chest x-ray with an abnormality which is concerning for a potential lung cancer is now flagged up to the Lung Cancer Team on a daily basis. Although, in the case of Mr Smith, his initial x-ray had been reported as normal as the changes were subtle.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Triage CT results daily after abnormal chest X-rays raise possible lung cancer, alerting the Lung Cancer Team and responsible consultant.

Verbatim wording from the response
“• There is daily triage of CT scan results performed following receipt of an abnormal chest x-ray where the potential for lung cancer has been raised by the reporting radiologist. It has been established that had this been the case for Mr Smith, this may have reduced the timescale between radiology reporting and receipt of that report by the requesting clinician by six days. This would also trigger the Lung Cancer Team and alert the patient’s Consultant.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.

Verbatim wording from the response
“• The request of additional tests can result in further delays: the Trust’s new protocol has standardised the pre-operative assessment process to try and minimise clinically unnecessary tests, recognising that each additional test builds in a potential time delay.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Allow PET scans to be requested before multidisciplinary discussion, requiring discussion after the PET-CT result.

Verbatim wording from the response
“• Patient’s cases do not need to be discussed at an MDT meeting in order to facilitate the requesting of a PET scan, but only following receipt of the PET CT result.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Increase surgical clinical capacity to prevent delays in clinic appointments.

Verbatim wording from the response
“• There has been an increase in surgical clinical capacity, preventing delays for clinic appointments.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain coordinated lung cancer working arrangements with UHNM, including weekly thoracic surgical outpatient clinics and multidisciplinary team attendance.

Verbatim wording from the response
“The Shrewsbury and Telford Hospital NHS Trust and UHNM continue to maintain close links and working closely together in the diagnosis and treatment of lung cancer patients. UHNM cardiothoracic surgeons attend SaTH weekly to operate surgical outpatient clinics and to attend weekly MDT meetings in person.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue quality improvement work towards compliance with the National Optimal Lung Cancer Pathway.

Verbatim wording from the response
“All improvements have also supported the Trust in quality improvement to work towards compliance with the National Optimal Lung Cancer Pathway which is due to come into practice by April 2020.”

Source location
2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Agree a standard operating procedure for referrals for surgical resection of proven or suspected lung cancer.

Verbatim wording from the response
“With regard to the delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma SaTH has produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached Standard Operating Procedure [SOP] – “Referral for surgical resection of proven or suspected lung cancer”. SaTH has implemented the SOP and will be responding to you separately.”

Source location
2020-0022-Response-from.-UNMH
Page 2 · response
Published 8 February 2020
Open published response
11 Feb2016
Brighton and Hove
Concerns raised1
1. Failure to ensure timely patient notification of cancer-diagnosis and specialist appointments
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marion Rose HOWES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure timely patient notification of cancer-diagnosis and specialist appointments
Wider context from the report
“(2) At this Inquest I was told that hospital was not considered the best place to impart the difficult news of a cancer and that this is dealt with by a Outpatients appointment being sent for the patient to meet the surgeon and the specialist nurse. In this particular case the patient died and in fact never knew the date of the appointment allocated, but the appointment of the specialist nurse, when the diagnosis is made, would be helpful and timeous and enable the patient to understand and prepare for what is to come. It seems to me that it would be a very much kinder way to proceed and would also mean that the sensible patient would be preparing him or herself for the surgery which is likely to follow. ”
Source location
Marion Rose HOWES · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Poor organisation of cancer diagnosis and treatment

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11

Concerns raised1

Failure to ensure timely patient notification of cancer-diagnosis and specialist appointments

Stated actions 3

Respondent positions 2

Stated actions 11