Prevention of Future Deaths report – Serena Roberts (22 October 2021)

Summary

Serena Roberts died as the result of an ovarian cancer which was not diagnosed until her death. She was initially seen for an ultrasound scan in April 2020 having reported symptoms of recurrent very heavy vaginal bleeding, and had been recommended to be referred to a gynaecologist for review but was not referred. In November 2020 her GP marked her referral letter as urgent, but this was entered as routine on the e-referral system and did not include important risk factor details regarding her BMI. Her condition worsened and on her second admission to hospital in March 2021 she died.

The Coroner in her report highlights concerns about significant delays in patients being seen in secondary care for gynaecological referrals from GPs, the understanding and application of NICE guidance on heavy premenstrual bleeding in General Practice and the documentation and processes relating to referrals to secondary care from the GP.

Content

In the report the Coroner states her main concerns as follows:

• The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs. The inquest was told that these delays had now increased. In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaecology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS.
• The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services.
• The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care. Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care.
• There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.

This report was sent to the Secretary of State for Health and Social Care and Tameside Clinical Commissioning Group.