Cancer: Risca mum died after urgent referral left in pigeon hole

A mum who died of throat cancer had an urgent medical referral left unread in a mail pigeon hole for a month, an inquest has heard.

Maria Shafighian, 59, from Risca, Caerphilly county, missed out on an appointment and her cancer had become untreatable by the time she was seen.

The coroner at the hearing in Newport called for changes to the health board's alert system.

Aneurin Bevan health board said it was developing electronic referrals.

Senior coroner Caroline Saunders ordered a prevention of future deaths report after the inquest in April.

The inquest found Ms Shafighian she died of natural causes after "opportunities missed to identify and treat [her] tumour earlier".

Ms Shafighian was first referred to the ear nose and throat (ENT) department by her GP in January 2020 after suffering "persistent hoarseness" in her throat and difficulty in swallowing.

A specialist ENT trainee assessed her the following month before ordering a CT scan - which found no signs of laryngeal cancer.

She was instead diagnosed with vocal cord palsy - a condition causing loss of control in the movement of the muscles that control the voice - and referred to the speech and language therapy department.

During a video consultation in April 2020 the "worrying development" of her swallowing difficulties was picked up.

She was referred back to the ENT team for an urgent assessment on 4 May 2020.

The referral was printed and left in the ENT department's pigeon hole, where it went untouched for a month, the inquest heard.

Ms Shafighian was then diagnosed with oesophageal cancer - a throat cancer more common in men in their 60s and 70s.

She received palliative chemotherapy and radiotherapy because she was not a candidate for surgical intervention and died in November 2020.

Ms Saunders said after the inquest "no evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team".

"There was no process for ensuring that the post was dealt with in a timely manner," she added.

While there were "opportunities missed to identify and treat Maria's tumour earlier," she said, "I could not determine on balance that this would have altered the outcome and hence the conclusion was death by natural causes".

Addressing the Aneurin Bevan University Health Board, Ms Saunders added: "In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."

She requested for the board to explain the processes by which changes in patients' symptoms are brought to the attention of the appropriate clinical teams "in a timely fashion", as well as policies in place to "underpin the use of alert systems and the internal postal service".

The health board's chief executive, Nicola Prygodzicz, responded to the report, saying it was developing an internal electronic referral form.

"That would need to be completed for any patients needing ENT input or an opinion," she explained.

"This would remove the need for paper letters or referrals to be sent, speed up the process, and provide an audit trail of receipt and action on the system."

Ms Prygodzicz said the referral letter that ended up in a pigeon hole had also been sent electronically to be triaged and an acknowledgement would then have been sent to Ms Shafighian to inform her she had been added to the waiting list.