Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0050, written 29 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jan 2025 |
|---|---|
| Reference | 2025-0050 |
| Deceased | Carla Smith |
| Coroner | Samantha Goward |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust · Norfolk and Norwich University Hospitals NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care 1 CORONER I am Samantha GOWARD, Area Coroner for the coroner area of Norfolk 2 CORONER’S LEGAL POWERS I 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. 3 INVESTIGATION and INQUEST 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: Metastatic Endometrial Cancer 1a) 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. 4 CIRCUMSTANCES OF THE DEATH 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 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 waiting lists, even for urgent referrals. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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. 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by March 26, 2025. 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 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Carla’s mother and partner Norfolk and Norwich University Hospitals NHS Foundation Trust The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Heacham Group GP Practice I have also sent it to CQC Regulation 28 – After Inquest Document Template Updated 30/07/2021 HSSIB, Healthwatch NHS England & NHS Improvement. who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 29/01/2025 Samantha GOWARD Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
Parliamentary Under-Secretary of State for Public Health and Prevention 39 Victoria Street London SW1H 0EU Our ref: HM Coroner Samantha Goward County Hall, Martineau Lane Norwich NR1 2DH By email: Dear Ms Goward, 24 March 2025 Thank you for the Regulation 28 report of 29th January 2025 sent to the Department of Health and Social Care about the death of Carla Smith. I am replying as the Minister with responsibility for Public Health and Prevention. Firstly, I would like to say how saddened I was to read of the circumstances of Carla Smith’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns across two key areas over the care provided by the Trust and its processes: 1) Firstly, significantly long waiting lists for gynaecological referrals, even for those on an urgent pathway. Consultants are left unable to catch up with the backlog and patients may significantly deteriorate while waiting, meaning they can miss out on treatment options. 2) Secondly, that there is no requirement or system in place to monitor the progress of those on a routine or urgent waiting list in the same way there is for those referred until a 28 day wait for suspected cancer. This leaves patients left waiting for excessive periods without requirement for their case to be reviewed. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. The Department has acknowledged the coroner’s findings regarding the tragic death of Ms Smith from endometrial cancer due to significant delays in her diagnosis and treatment. Recognising the serious risks associated with long waiting times, it has reaffirmed its commitment to reducing patient wait times and improving access to timely care. A key focus is restoring the 18-week Referral to Treatment standard, ensuring that 92% of patients receive treatment within this timeframe. Addressing the backlog and delays in gynaecology, which have faced increasing demand and performance challenges, is an important part of the overall return to constitutional standards. To improve access to care, NHS England is supporting the expansion of community-based services, including piloting gynaecology pathways in Community Diagnostic Centres. These efforts aim to bring diagnostic and specialist care closer to patients, reducing pressure on hospitals and speeding up the referral process. Additionally, measures are being implemented to strengthen safeguards between primary and secondary care, including the use of specialist advice and triage services. Pre-referral and post-referral advice mechanisms will provide a safety net for patients awaiting appointments, enabling better communication between GPs and specialists to ensure timely assessments. The Department is also addressing delays in diagnostic test results, a key factor in this case. The turnaround time for the patient’s biopsy results was excessively long, contributing to the cancer’s progression from stage 1 to stage 4 before diagnosis. Improving diagnostic reporting times is a priority. The expected turnaround time for histopathology slides is 80% within 7 days and 90% within 10 days. For imaging tests, NHS England published guidance in August 2023 that set out expectations on turnaround times, and an expectation that no test should take longer than 28 days to report. Investments in digital diagnostic transformation, including automated test requesting and result-sharing systems, will help ensure faster and more efficient processing of test results. Enhancements to the NHS App will also allow patients to receive their results more quickly. Reforms to cancer waiting time standards are being introduced to improve early detection and streamline the diagnostic process. The outdated two-week wait standard is being replaced with a focus on the Faster Diagnosis Standard, ensuring that 75% of patients receive a diagnosis within 28 days. Additional measures include a 62-day standard from referral to treatment and a 31-day standard from decision to treatment. These changes aim to enhance efficiency and provide a clearer framework for monitoring and improving cancer pathways. The case also highlighted systemic issues in how urgent referrals are processed. While the second GP appropriately referred the patient for further investigation as an urgent referral, the referral was triaged as urgent rather than on the urgent suspected cancer pathway, leading to a four-month delay before further testing. The absence of clear criteria for upgrading cases like this to an urgent suspected cancer pathway contributed to the delay. The original GP should have initiated the referral earlier, specifically on 23 August, rather than waiting until a different GP reviewed the scan on 27 September and made the urgent referral. It is crucial for GPs to adhere to referral guidelines, ensuring timely urgent and USC referrals for postmenopausal bleeding. Further, delays in histopathology reporting meant the biopsy results took several months, significantly impacting the patient’s prognosis. The Department recognises the need for improved triage and monitoring of patients on waiting lists to prevent similar outcomes. To address these challenges, NHS England is expanding elective care reform initiatives, increasing the capacity of Clinical Diagnostic Units to perform more tests such as hysteroscopies. Digital improve patient experiences while waiting for care. These steps aim to reduce overall wait times, improve diagnostic turnaround, and ensure that patients with potential cancer symptoms receive urgent attention. innovations are also being introduced to By investing in workforce expansion, digital transformation, and streamlined referral pathways, the Department aims to prevent future delays in cancer diagnosis and treatment. Efforts to improve coordination between primary and secondary care, enhance diagnostic reporting efficiency, and prioritise faster treatment access will be critical in addressing the issues raised by the coroner’s report and ensuring better outcomes for patients in the future. Once again, I would like to extend my deepest sympathies to Ms Smith’s family and friends on this tragic case. hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
See every Prevention of Future Deaths report matching The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.