Milos JANKOVIC · Prevention of Future Deaths report

On 26 November 2024 I commenced an investigation into the death of Milos JANKOVIC. The investigation concluded at the end of the inquest on 18/09/2025. The narrative conclusion of the inquest was that Mr Jankovic had been diagnosed with Barrett’s Oesophagus in 2014, but lost to follow up surveillance due to a bowel cancer taking priority. Sadly, in 2020 he began to show symptoms of cancer and testing established that he had developed brain metastases of a primary oesophageal cancer.

Had Mr Jankovic been under surveillance, it is more likely than not that he would have by 2023, been seen by specialists in Barrett’s Oesophagus who would have been able to offer various options for ongoing surveillance and potential treatments. However, there is insufficient evidence that this would have changed the outcome for Mr Jankovic, given the nature of the disease and its known poor outcomes despite surveillance.

1a Metastatic Oesophageal Cancer

1b Barrett's Oesophagus

1c

II

The Inquest focused upon:-

a. The practical aspects of administration of surveillance for Barrett’s patients in primary and secondary care; and

b. Whether the outcome would have been different for Mr Jankovic if surveillance had occurred as it should have

.

(1) There are two cases that have recently come to my attention within the Cardiff area where patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from oesophageal cancers;

(2) There are inadequate processes in place to address this lacuna, particularly in primary care where a patient may not be a regular attender;

(3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not currently benefit from such a recall exercise/audit, even though it is well-established to be a pre-cancerous condition; and

(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance.