Carla Marie SMITH · Prevention of Future Deaths report

On 15 June 2023 I commenced an investigation into the death of Carla Marie SMITH aged 38, date of death 07 June 2023. The investigation concluded at the end of the inquest on 24 January 2025.

The medical cause of death was:
1a) Metastatic Endometrial Cancer
1b)
1c)
2)

The conclusion of the inquest was:
Died due to a naturally occurring condition, a rapidly progressing cancer, the diagnosis and treatment of which was delayed due to a number of missed opportunities.

Carla Smith had a history of excessive vaginal bleeding. She first attended her GP surgery in July 2022 and an ultrasound scan was arranged. The report received 23 August 2022 showed a thickened endometrium of 22 millimetres. This should have led to a referral to the gynaecology team. After a review by a different GP and a discussion with Carla on 27 September 2022, an urgent referral was made with an anticipated wait of 4-6 weeks. When triaged by specialists at the hospital, the referral should have been upgraded to a 2 week wait pathway. Carla was not seen until 31 January 2023. A biopsy on that day was marked as routine instead of a 2 week wait. There was a delay in the sample being processed and this was chased after Carla attended hospital again as an emergency on 15 April 2023 due to ongoing heavy bleeding. A CT scan showed signs suggestive of advanced endometrial malignancy with disseminated metastasis. This prompted a report on the January biopsy, which was said to show grade 1 womb cancer at that time. After a further biopsy and investigations in April 2023 it was felt that Carla had stage 4 cancer. While an initial plan was made for surgery, due to the unusually aggressive nature of the cancer, Carla rapidly deteriorated and was sadly not suitable for surgery and palliative care commenced. She died on 7 June 2023.

During the course of the Inquest, it was apparent that there were a number of missed opportunities to refer Carla for treatment and to use the correct pathway to do so and there were also significant delays in receiving results from the laboratory and due to lengthy waiting lists, even for urgent referrals.

1. During the course of the evidence, I heard from Consultants at two hospitals, and read evidence from others. The evidence I heard is that, at that time there were significant waiting lists, even for those on an urgent pathway. I heard that these issues persist and that, in relation to gynaecology referrals which was the subject of this inquest, where the expected waiting time would previously be 4-6 weeks for an urgent referral, one hospital has a waiting time of 18 weeks, the other 30 weeks (and 60 weeks for routine). I was advised by one Consultant that they do not know how they can catch up with this backlog. I am aware that this is not a problem that is unique to just the two Trusts from whom evidence was heard.

2. The cause for concern is that some patients may significantly deteriorate while on such lengthy waiting lists. In some cases, this may mean that they lose some treatment options due to their condition advancing. This leads to a risk of future deaths.

3. The other concern I have following the evidence heard, is that if someone is on a routine or urgent waiting list, there is no requirement or system in place to monitor their progress. I was advised that those referred under a 2 week wait (which I am now advised has been changed to a 28 day wait) for suspected cancer, will be monitored to ensure that the timescale is met. There is no such requirement for the other waiting lists. This may lead to patients being left waiting for excessive periods, without any requirement for their case to be reviewed to ascertain if it remains suitable for such a lengthy wait, or if a new referral needs to be made on a different pathway.