“I am concerned that there is not any or insufficient guidance available to clinicians in…”

The coroner’s concerns

– (1) I am concerned that there is not any or insufficient guidance available to clinicians in regard to possible radiation induced sarcoma, or first line investigations for patients with breast implants to be able to see down to the chest wall. The Radiologist, Surgeon and Nurse advised that they did not have any specific guidance in relation to possible radiation-induced sarcoma, from the Royal Marsden advised in written evidence, that radiation induced sarcomas are increasing in incidence as more primary breast cancer patients are now offered breast conserving surgery with wide local excision and radiotherapy, rather than mastectomy alone (previously there was no radiation). Therefore, in his view the increasing use of radiotherapy leads to increased number of patients developing radiation induced sarcomas. As said from the Royal Marsden, diagnosis requires the treating clinician to recognise that this is a possibility. Furthermore, as advised in his experience the difficulties in diagnosis are that they are sometimes not recognised by primary and secondary care teams who are the first to see the patient. In evidence the Radiologist confirmed that the Royal College of Radiologists do not have a protocol for patients who have had previous radiotherapy and implant. Furthermore, Nurse Diagnostician confirmed there was no protocol in the ABS Best Practice Diagnostic Guidelines for radiation induced sarcoma where a patient has had an implant. (2) I have a concern regarding the current surveillance period of 5 years provided to patients with breast cancer considering the latency period of radiation induced sarcoma is 10 years. (3) I have concerns regarding the system in place at Ashford Hospital for 2 week follow ups following an aspiration following an initial assessment at the One Stop Clinic. Following the aspiration Mrs Stokes received, the Nurse advised in evidence Mrs Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly communicated to the family. This would have allowed for further follow up in case the bulge had increased in size and in pain and could have potentially identified the need to investigate further.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0436

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0