Sara GRINNELL · Prevention of Future Deaths report

On 22 April 2022 I commenced an investigation into the death of Sara GRINNELL . The investigation concluded at the end of the inquest 17/09/2024 . The conclusion of the inquest was Ms Grinnell died as a result of the progression of endometrial cancer. There were delays in investigating her symptoms which may have identified potential treatment options at an earlier stage.

1a Metastatic Endometrial Cancer

1b

1c

II

These were recorded as :-

Mrs Grinnell had been suffering with excessive vaginal bleeding since 2015. She suffered with significant menorrhagia from around 2018 and had a cervical polyp removed in 2018. She was referred to the Gynaecology Department in 2019 due to the ongoing menorrhagia. An ultrasound scan performed in June 2019 resulted in an Urgent referral to the Gynaecology Department. She was sent 2 letters by the gynaecology department approx. 22 weeks after the Urgent referral, however it appears that Sara Grinnell did not receive the letters. She was referred again in Aug 2020, Jan 2021, and in May 2021 she was referred under the Urgent Suspected Cancer pathway. In June 2021, Ms Grinnell was diagnosed with endometrial cancer. A planned hysterectomy on 10 September 2021 was postponed due to insufficient theatre time. Her treatment options were limited to palliative. She sadly died on 11 April 2022 at Princess of Wales Hospital.

She deteriorated, and passed away on 11/4/22

The Inquest focused upon:-

a. The timeline of referrals to and appointments with the Gynaecology Department and investigations that took place
b. The treatment received by Mrs Grinnell

(1) 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) 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) 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.

(3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis.