Anthony Eric Williams · Prevention of Future Deaths report

On 3rd May 2023 I commenced an investigation into the death of Anthony Eric Williams. The investigation concluded on the 27th September 2023 and the conclusion was one of Narrative: Died from the complications of bowel cancer not diagnosed and not treated until it had reached an advanced stage. The medical cause of death was 1a) Metastatic Adenocarcinoma of the bowel

Anthony Eric Williams presented at Tameside General Hospital with abdominal pain and was diagnosed with constipation on 7th October 2022. On 12th October a telephone consultation with a GP resulted in further discussion of treatment for constipation. On 3rd November he was found by the GP to have a distended abdomen and was referred on the two-week cancer pathway. CT scans found a mass in his bowel. Biopsies were initially inconclusive for cancer. A PET scan on 8th February confirmed advanced colorectal cancer. A stoma was inserted laparoscopically on 14th February to assist with his bowel symptoms. He was not seen for chemotherapy consideration until 6th March 2023. His health had deteriorated significantly since his referral on the cancer pathway and his suitability for chemotherapy was borderline. The plan was to start it around 17th March. In the period he developed spinal cord compression and received radiotherapy which was given on 21st March. He continued to deteriorate with the cancer having spread into his brain. Chemotherapy was not started until 4th April 2023.He deteriorated rapidly with the cancer having spread aggressively. He died at Stamford Court on 28th April 2023.

The inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers. This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started.

The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome.

Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing treatment and again reduced the chances of a successful treatment outcome.