Prevention of Future Deaths reports · 2024

Sara Grinnell

Regulation 28 report to prevent future deaths, reference 2024-0497, written 17 Sep 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report17 Sep 2024
Reference2024-0497
DeceasedSara Grinnell
CoronerPatricia Morgan
Coroner areaSouth Wales Central
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

GRAEME HUGHES CORONER'S OFFICE
URTH E
HIS MAJESTY’S THE OLD CO folky
SENIOR CORONER COURTHOUSE STREET
PONTYPRIDD
SOUTH WALES CENTRAL
CORONER AREA CF37 1JW
Telephone
Email}
ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

The Chief Executive Cwm Taf Morgannwg University Health Board

CORONER
| am Patricia Morgan Area Coroner, for the coroner area of South Wales Central.
CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

On 22 April 2022 | 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

“4 Joincumsrances OF THE DEATH

Coroner's Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW
Phone/Ffén (01443) 281100 Fax/Ffacs (01443) 485862

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 poly 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

During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows.

(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
ito 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.

Coroner's Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 12'" November 2024. Only I, the Coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION
| have sent a copy of my report to family who may find it useful or of interest.
| have also sent a copy to the Chief Executive of Swansea Bay University Health Board

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest. You may make representations to me, the coroner, at the time of your response,
about the release or the publication of your response by the Chief Coroner.

17 September 2024

SIGNED: 9% “terse

Patricia Morgan Area Coroner for South Wales Central Coroner Area

Coroner's Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Cwn Taf Morgannwg University Health Board (PDF)
Cyfeiriad Dychwelyd/ Return Address: 
Bwrdd Iechyd Prifysgol 
Cwm Taf Morgannwg 
Pencadlys  
Parc Navigation, 
Abercynon  
CF45 4SN 

Cwm Taf Morgannwg 
University Health Board  
Headquarters 
Navigation Park 
Abercynon 
CF45 4SN 

Ffôn/Tel: 

Eich cyf/Your Ref: 
Ein cyf/Our Ref: 
Ebost Email: 
Dyddiad/Date: 

8 November 2024 

Mrs Patricia Morgan 
Area Coroner 
South Wales Central 
Coroner’s Office 
The Old Courthouse 
Courthouse Street 
Pontypridd 
CF37 1JW 

Dear Mrs Morgan 

Regulation 28 Report to Prevent Future Deaths  

I  am  writing  in  response  to  the  Regulation  28  Report  issues  to  Cwm  Taf  Morgannwg 
University Health Board (CTMUHB) on 17 September 2024 following the conclusion of the 
inquest into the death of Sara Grinnell.  

The Health Board values the opportunity to learn from the tragic events relating to Sara’s 
death. The Regulation 28 report identified three key areas of concern listed below: 

(1) 

(2) 

Following an ultrasound scan performed in June 2019, and urgent referral to 
the Gynaecology Department, there was extensive delay in excess of 22 weeks 
to contact the patient with an urgent appointment.  
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.  

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales 

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

This  response  is  limited  to  the  actions  taken  by  CTMUHB  in  relation  to  the  Coronial 
concerns, each of which will be responded to individually in order to provide assurance 
on the improvement actions implemented.  

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 to contact the patient with an urgent appointment.  
The Welsh Government has established clear guidelines for managing referral-to-
treatment waiting times to ensure timely access to care. Under the mandate issued 
in December 2009, all referrals to secondary care are expected to be addressed 
within 26 weeks for at least 95% of cases. 

Ms.  Grinnell’s  waiting  time  of  22  weeks,  though  understandably  lengthy,  was 
within the official timeframe for urgent cases. It is important to note that  only a 
referral  marked  as  “urgent  suspected  cancer”  would  have  triggered  a  more 
accelerated pathway in line with NHS guidelines, designed to expedite diagnosis 
and treatment for cases suspected of malignancy. 

With  the  benefit  of  hindsight,  it  might  have  been  beneficial  for  Ms.  Grinnell’s 
referral to have been designated as “urgent suspected cancer” initially, which may 
have  allowed  for  management  under  the  national  single  cancer  pathway  for 
endometrial cancer.  

2)  The  means  of  contacting  the  patient  for  an  Urgent  Gynaecology 
further 

appointment  was  via  written  correspondence  without 
consideration of other means via telephone, email, or via G.P.  

Our  primary  communication  method  with  Ms.  Grinnell  has  consistently  been 
written  correspondence.  We  made  three  documented  attempts  to  reach  her  on 
November 21st, November 28th, and December 12th, 2019. Historically, written 
communication has been effective, as evidenced by Ms. Grinnell's response to a 
January  2018  letter,  which  she  received  and  then  attended  the  scheduled 
appointment.  

Following her GP’s urgent suspected cancer referral, we continued to communicate 
primarily  by  letter,  a  method  proven  both  adequate  and  effective  in  delivering 
essential  information.  Additionally,  on  May  28th  2019,  there  is  documented 
evidence  of  a  telephone  conversation  between  Ms.  Grinnell  and  hospital 
management, which occurred shortly after her urgent referral to secondary care, 
following the 24-hour response protocol. 

There  is  no  indication  that  an  alternative  communication  method  would  have 
increased  Ms.  Grinnell’s  likelihood  of  attending  any  appointments  during  2019–
2020, particularly given the heightened difficulties posed by the pandemic. It  is 
also  notable  that  from  January  2019  to  December  2020,  Ms.  Grinnell  did  not 
initiate  contact  with  her  GP.  Her  next  recorded  contact  with  the  GP  occurred  in 
January 2021. 

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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.  

The Health Board respectfully does not agree. Following Ms. Grinnell’s referral for 
worsening symptoms, her case was reviewed by both her GP and a specialist, who 
determined that her symptoms did not meet the criteria for an urgent suspected 
cancer (USC) referral. Despite this assessment, multiple attempts were made to 
contact her. Ultimately, Ms. Grinnell was removed from the waiting list due to a 
period of non-engagement with healthcare providers.  

A letter dated 12th December 2019, sent to both Ms. Grinnell and her GP, explicitly 
stated  that  should  her  condition  become  a  renewed  concern,  she  could  be 
reinstated on the waiting list within three months. This correspondence provided 
both Ms. Grinnell and her GP with a direct telephone number for the booking office, 
should  re-engagement  be  necessary.  The  letter  reflects  a  proactive  approach, 
carefully considering her symptoms and incorporating safety-netting measures to 
mitigate the risk of a missed follow-up opportunity. 

As  no  further  contact  was  made  by  Ms.  Grinnell  or  her  GP  within  the  specified 
period  or  throughout  2020,  it  is  reasonable  to  conclude  that  she  exercised  her 
autonomy  in  choosing  not  to  seek  further  care—a  decision  that  healthcare 
providers must respect. 

The Health Board would like to reiterate that no communication was received from 
Ms. Grinnell or her GP until January 2021. In our view, the period before January 
2021 represented the critical window for early intervention. However, the missed 
opportunity here is multifactorial, influenced by apprehension about hospital visits 
during the COVID-19 pandemic and the challenges in healthcare delivery due  to 
pandemic-related pressures. 

As a Health Board, we endeavour to achieve required standards of care for women. An 
improvement  plan  for  Urgent  Suspected  Cancer  referrals  has  been  developed  and 
included within this response for assurance.  

I  hope  that  this  response  provides  explanation  and  assurance  that  CTMUHB  are 
committed  to  fully  address  the  concerns  in  the  Regulation  28  Report  relating  to  Sara 
Grinnell’s death.  

Please do not hesitate to contact Dr Dom Hurford, Executive Medical Director if you would 
like  further  assurances  or  if  you  require  a  meeting  to  discuss  any  areas  of  continuing 
concern.  

Yours sincerely 

Prif Weithredwr/Chief Executive 

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CTMUHB Improvement plan 

Action  

Impact  

Capital investment  

Opening of Gynae 
Hub at RGH 

The Gynae Hub passed through three stages until it is fully 
operational since July 2024. 

It includes Gynae Day Assessment Unit (GDAU) and Early Pregnancy 
Unit (EPU); the rapid access cancer service (GRAS); hysteroscopy 
and colposcopy services; several outpatient clinics; increase in urgent 
gynaecology services and ultrasound scanning facilities.  

This increased our capacity in CTM, offered multiple services as one 
shop floor, markedly improved women experience and reduced 
unnecessary delays. 

This facility will also create an opportunity to bring Bridgend locality 
patients through the GRAS cancer service. 

Purchase of 
additional 
examination bed 
(compatible with 
ultrasounds 
scanning) 

Additional scanning capacity will provide flux in the system to 
increase the number of UCS USS when an increase in referrals is 
seen. When referrals are reduced scans will be utilised for urgent 
review, or stage 2 routine patients. Increase by 4-5 scan sessions per 
week; three of them will be dedicated for USC patients with extra 
capacity of 18 patients per week 

Purchase of 
additional ultrasound 
scanner  

Additional scanning capacity will provide flux in the system to 
increase the number of UCS USS when an increase in referrals is 
seen. When referrals are reduced scans will be utilised for urgent 
review, or stage 2 routine patients. Increase by 4-5 scan sessions per 
week; three of them will be dedicated for USC patients with extra 
capacity of 18 patients per week. 

In addition to creating 4 extra one stop clinics (scan and assessment) 
with capacity of 40 patients per month. 

Additional ultrasound scan clinics for USC waiting patients.  

Extra one stop (scan and assessment clinics with capacity of 10 
women per clinic). 

This brought our waiting time for 1st outpatient appointment to 
around 10 days. 

Additional hysteroscopy sessions will expand the existing Gynae 
Cancer Rapid access service (GRAS), creating enough capacity to 
repatriate Bridgend PMB USC cases back to CTM. 

Develop extra scan 
clinics to tackle the 
back log created as a 
result of sonographer 
sickness and reduced 
activity 

Develop extra 
Hysteroscopy 
sessions in the newly 
developed Hub (in 
process) 

Process improvements  

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Improve triaging 
process; update the 
triage proforma, 
agreement of daily 
triage allocation; 
implementation of 
electronic triage 
(WPRS) 

Update triage form to include correct process for GRAS and non-USC 
hysteroscopy referrals. To ensure triage is done within 24-48 hours 
consistently.  

Electronic triage (in process) will make allocation of triage duty far 
easier from any site, improving cover for leave etc and ensuring 
timely triage. 

Establish CTM Gynae 
cancer oversight 
meetings 
(implemented from 
11th May) 

Gynaecology directorate hold internal care group meetings (across all 
sites) to discuss cancer performance, review the patients, address 
escalations etc. The anticipated impact is improved communication 
across sites, particularly in terms of tracking, care plans for malignant 
patients, addressing long waits and ensuring timely dates for 
diagnostic and treatment procedures. 

Improve MDT 
attendance and 
performance 

Improved clinical oversight of patients listed for MDT; timely 
treatment plans; improved collaborative working with rad and path 
teams; reduce delays for agreement of further diagnostic or 
treatment plans. 

Rota for CNS to 
ensure daily review 
of patients admitted 
with cancer in PCH 
with improved 
communication with 
the on call team 

Improve harm 
review process 

Ensure continuity of care for women admitted with cancers. Improve 
the communication and the plan of care for our women. 

Ensure robust clinical MDT review of patients waiting >104 days 

Workforce improvements  

Administrator is essential to provide co-ordination to the expansion of 
the GRAS service, including all booking of appointments, working 
across CTM and SB PAS systems to outcome patient pathways, 
liaising with medical records, consultants, secretaries, cancer teams, 
CNS, radiology and pathology across sites. 

Secure 
administrative 
support for 
expansion of the 
Gynaecology Rapid 
Access  service 
(GRAS) to include 
Bridgend population 
(patients presented 
with postmenopausal 
bleeding are current 
seen at NPTH) 

Re-banding of EPU 
nurse to become 
nurse sonographer 

Additional scanning capacity provided flux in the system to increase 
the number of UCS USS when an increase in referrals is seen. Extra 
capacity is utilised for urgent review, or stage 2 routine patients. 

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales 

 
 
 
 
 
 
 
 
 
 
 
 
 Appoint team leader 
for Gynae Hub 
(nursing) 

The team leader will oversee all activity in the Gynaecology Hub, 
ensuring appropriate staffing cover, efficient use of resource etc. This 
appointment will release the nurse hysteroscopist to undertake more 
clinical duties. 

Improved tracking for Gynae services across sites. 

Appoint cancer 
tracker for Gynae 
services to improve 
efficiency across 
sites 

Repatriate Service 
Level Agreement 
with SBUHB 

Improve access to women living around Bridgend locality which will 
reduce the waiting times for the 1st outpatient appointment and help 
to manage women around Bridgend locality to be treated in the 
standard required time frames. 

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un 
iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond 
accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales

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