June Thompson

Acting Chief Executive Officer 
The John Radcliffe 
Headley Way 
Headington 
Oxford 
OX3 9DU 
Tel: 01865 221383 

02 June 2025 

Your ref: 

Mr Guy Davies  
HM Assistant Coroner for Cornwall & the Isles of Scilly Coroner’s Area 

Sent via email only to: 

Dear Mr Davies 

Regulation 28 Report/Prevention of Future Deaths Letter 
Inquest into the Death of Mrs June Thompson 

Following the death of Mrs June Thompson and subsequent inquest hearing from 26 – 
27 March 2025, I write as Acting Chief Executive Officer of Oxford University Hospitals 
NHS Foundation Trust (OUH), to provide a response to your Regulation 28 Report dated 
6 April 2025.  

I would like to start by expressing to Mrs Thompson’s husband and family how sorry I 
am for their loss.  

Mrs  Thompson  was  referred  to  OUH by  Royal Cornwall Hospital Truro  (RCHT)  on  2 
June  2023  to  consider  a  palliative  hip  replacement  for  presumed  metastatic  cervical 
adenocarcinoma of the right hip. She was seen in out-patient clinic at OUH on 19 June 
2023 and had an ultrasound guided biopsy of her pubic ramus on 4 July 2023. This was 
reported  on  12  July  2023  as  showing  a  high-grade  small  cell/  spindle  cell  malignant 
tumour which was discussed at the Oxford Sarcoma MDT Meeting on 10 July 2023; the 
MDT recommended discussion with the RCHT Gynaecology MDT to compare the new 
histology with previous histology from 2019.  

A referral was also made simultaneously to the OUH Gynaecology Oncology service 
with a view to seek an opinion about pelvic exenteration. Mrs Thompson attended OUH 
gynaecology  clinic on 19  July 2023  where  it was  assessed  that the  oncology  picture 
was unlikely to be a recurrence of cervical cancer. A whole body PET scan was planned 

Page 1                                                From the office of the Acting Chief Executive Officer 
Oxford University Hospitals NHS Foundation Trust 

 
 
 
 
   
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 at  OUH  as  well  as  recommended  referral  to  the  local  Cornwall  Pain  Team  and  an 
ultrasound scan in Cornwall to exclude a Deep vein thrombosis. 

Mrs Thompson had a CT angiogram at RCHT on 26 July 2023 to assess the cause of 
limb  swelling  which  was  thought  to  be  vascular  occlusion  from  the  rapidly  growing 
sarcoma in her hip. She also had a CT scan of her thorax, abdomen and pelvis on 26 
July  2023.    Mrs  Thompson’s  case  was  further  discussed  at  the  OUH  Sarcoma  MDT 
Meeting  on  31  July  2023.  The  decision  was  to  proceed  with  a  right  hindquarter 
amputation for local control of aggressive disease. It was also noted that in the CT scan 
from 26 July there were at least 3 lung nodules, potentially metastases but considered 
to be indeterminate at that stage. It was noted on 31 July that Mrs Thompson was still 
awaiting a PET scan to determine the status of the lung nodules. 

Mrs Thompson declined to have a PET scan on 1 August 2023 as she felt unable to 
tolerate the whole body scan. On 2 August 2023 the RCHT Gynaecology Nurse and 
OUH sarcoma nurse discussed the OUH MDT outcome with Mrs Thompson. 

The CT angiogram scan from 26 July at RCHT had not been formally reported however 
the treating OUH orthopaedic sarcoma consultant surgeon reviewed the images on 7 
August 2023 and saw for himself the venous occlusion and external compression of the 
artery  by  the  tumour.  The  OUH  treating  consultant  surgeon  also  noted  some  lung 
nodules on the CT angiogram images. The treating consultant surgeon assessed that 
hindquarter amputation was still indicated both for local control and due to threatened 
limb (impending vascular occlusion).  At this stage the purpose of the surgery was still 
felt to be potentially curative as the status of the lung nodules was not certain as Mrs 
Thompson was unable to tolerate the PET scan.  

On 9 August 2023 Mrs Thompson attended the OUH Sarcoma Specialist Pelvic Clinic 
and was admitted urgently for pain management, IVC filter and a new MRI to plan for 
proposed surgery. A new MRI of the pelvis and right lower leg was performed. She was 
also  seen  by  the  Occupational  Therapy  and  Sarcoma  Specialist  Nurse  teams  in 
preparation for surgery. On 11 August 2023 the inferior vena cava filter was inserted 
and after optimising pain control, she was discharged until the planned surgical date of 
23 August 2023. 

On 15 August 2023 the report of the CT angiogram and CT chest, abdomen and pelvis 
performed on 26 July 2023 in Cornwall was emailed to the OUH Sarcoma administrative 
team. The report noted multiple new lung metastases, progressive right acetabular bony 
destruction,  venous  obstruction  of  right  external  iliac  vein  by  tumour  invasion,  and 
grossly  abnormal  arterial  supply  to  the  lower  limbs.  The  CT  angiogram  result  was 
uploaded to the OUH Electronic Patient Record but not communicated to the treating 
Consultant Surgeon. 

Mrs Thompson was admitted to OUH and proceeded to a right hindquarter amputation 
on 23 August 2023.    

Page 2                                    From the office of the Acting Chief Executive Officer 
Oxford University Hospitals NHS Foundation Trust 

 
 
 
  
 You recorded a narrative conclusion on 27 March 2025 as follows: “June (Thompson) 
, Cornwall from Radiation 
died on 1 November 2023 at 
Induced Metastatic Sarcoma, following radiotherapy treatment for cervical cancer” 

The medical cause of death was confirmed after hearing evidence from Royal Cornwall 
Hospital clinicians, OUH clinicians and GP representative by you to be: 

1a Radiation Induced Metastatic Sarcoma 

In  your conclusion  you  set out  four areas  of  concern,  and  for  each  I  can provide  the 
following additional information outlining how we are addressing the concerns: 

1.  There is a risk of future deaths from decisions to proceed with major 

operations without the surgical team having full knowledge of disease 
progression, this could include operations that may be unnecessary  

To address this risk across the Trust, a new Standard Operational Protocol (SOP) has 
been developed for Management of Patient Related Clinical Information received from 
another  Department  /  Trust  /  Organisations.  I  attach  a  copy  of  this  SOP  which  has 
already been implemented in the gynaecology and sarcoma services and is being rolled 
out across the Trust.   

In  addition,  a  separate  SOP  for  the  Oxford  Radical  Pelvic  Surgical  team  has  been 
revised to include a prompt to check for test result reports from external NHS Trusts 
before  proceeding  to  treatment.  If  test  results  are  requested  within  OUH  then  the 
Electronic  Patient  Record  already  automatically  notifies  the  test  requestor  and  the 
named  consultant  of  the  result.    The  updated  SOP  has  been  distributed  to  all  pelvic 
surgical  consultants  and  will  be  shared  with  Clinical  Leads  for  Surgery  for  learning 
across the Trust. I attach a copy of this clinical SOP. 

The  learning  from  this  inquest  and  the  subsequent  investigation  (see  below)  was 
highlighted  at  the  Trust  wide  Safety  Learning  and  Improvement  Conversation  on  17 
April  2025  and  the  key  learning  of  communicating  test  and  scan  results  performed 
outside  OUH  to  the  named  consultant  was  included  in  the  summary  slide  from  this 
meeting which was circulated to all clinical teams.  A Trust wide Patient Safety Message 
email highlighting the importance of reviewing all radiology reports prior to surgery has 
been drafted and will be circulated to all OUH staff in the next 4 weeks. 

2.  The error has not been reported through the OUH Incident Reporting 

process  

We acknowledge that the incident was not reported in our incident reporting system until 
after the inquest.  The Sarcoma service has an open and transparent reporting culture 
as evidenced by 37 incidents that have been reported in the last 2 years with 26 of these 
being  of  ‘no  harm’.    We  have  fed  back  to  the  team  the  importance  of  reporting  any 
patient  safety  incidents  and  will  send  a  Trust  wide  Safety  Message  emphasising  the 
importance  of  reporting  all  safety  incidents  including  ‘no  harm’  (previously  known  as 
‘near misses’) to ensure learning to prevent future harm. 

Page 3                                    From the office of the Acting Chief Executive Officer 
Oxford University Hospitals NHS Foundation Trust 

 
 
 
  
 
 3.  The error has not been investigated to establish why it happened and how 

to prevent a reoccurrence 

The  incident  has  now  been  reported  and  investigated  in  line  with  the  Trust’s 
implementation of the Patient Safety Incident Response Framework. The learning from 
the inquest and this investigation has been highlighted at the Trust-wide Safety Learning 
and  Improvement  Conversation  and  circulated  to  all  clinical  teams.  It  will  also  be 
presented  at  the  next  Sarcoma  Surgery  Clinical  Governance  meeting,  Trust  Clinical 
Governance Committee and the OUH Mortality Review Group over the next 2 months.   

4.  There is no policy, guidance or standard operating procedure regarding 

how to process medical reports being received at OUH from other 
hospitals. 

As summarised above, to address this risk across the Trust, a new SOP has been 
developed to ensure that any clinical information received by OUH from other NHS 
Trusts is shared promptly with all relevant clinicians, and the learning from this inquest 
has been highlighted at the Trust wide Safety Learning and Improvement 
Conversation and circulated to all clinical teams. 

Thank you for bringing to our attention the issues above, which have allowed us to 
take action to address the risks you identified. I hope that this response reassures you 
that we have taken your concerns very seriously and implemented appropriate actions 
to prevent a similar incident happening in the future.  

Yours sincerely 

Acting Chief Executive Officer 

Attachments: 

1.  New Gynaecology/Sarcoma Administrative SOP 
2.  Updated Oxford Radical Pelvic Surgery SOP 

Page 4                                    From the office of the Acting Chief Executive Officer 
Oxford University Hospitals NHS Foundation Trust