“There was an overall delay in reaching any diagnosis in Bill’s case and, therefore, any…”

The coroner’s concerns

– i. There was an overall delay in reaching any diagnosis in Bill’s case and, therefore, any treatment plan being implemented. ii. There was a delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days. iii. There was a delay from the MDT referring the case to the Consultant, to an appointment taking place in May 2023. iv. There was an additional delay between the further CT scan ordered by the Consultant, which took place on 5 June, and the MDT which considered the results and treatment plan on 29 August, notwithstanding the fact that the MDT meet weekly and Bill’s case 2 could have been considered at any of those meetings. v. A further delay occurred from 4 September, as Bill had been assessed as unfit for surgery due to his HBA1c reading. Whilst this is unlikely to have been related to the cancer, there was likely to have been an opportunity, had his case been progressed earlier, at which his HBA1c was at an acceptable level for the procedure to be carried out. vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter‐relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer. vii. A final delay occurred in the results of a CT scan, the results of which were not available until 15 January. By this time, the cancer had spread throughout Bill’s body and became untreatable. viii. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained. One example is the default of a referral or request to “routine”. ix. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and treatment.

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, 2024-0708

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