Sarah Catherine Daniels died from metastatic signet ring adenocarcinoma of the appendix on April 15, 2025, after a nine-month delay in receiving her test results, an inquest has found. The delay between her surgery and the pathology results was deemed "unacceptable" by the coroner, who noted it likely impacted her treatment and survival.
Dr. Kein Yim, a consultant in clinical oncology, stated that by March 2025, Sarah's condition had declined to the point where she was too frail for further chemotherapy. Mohamed Khalifa, a consultant in obstetrics and gynaecology who leads gynaecological cancer multidisciplinary team (MDT) meetings for the Cwm Taf health board, provided evidence highlighting the significance of the nine-month pathology delay. He said Sarah lost critical time in her cancer treatment due to the wait between surgery and histology, and that her Risk of Malignancy Index (RMI) had been "incorrectly reassuring" to her and her family.
"When she died might have been different if the chemotherapy or other treatment had been started sooner," Khalifa said. "The delay of [nine] months between surgery and histology was unacceptable."
Initial aspects of Sarah's care, including her GP referral and an MRI scan on November 10, were handled appropriately. The coroner noted that at that stage, there was "low suspicion" of cancer, and it was considered reasonable that medics did not initially order an MRI scan of her entire abdomen, which might have revealed the appendix cancer. Evidence indicated that the mass did not initially appear cancerous, and samples were sent for testing as expected.
However, the pathology department was found to be "completely overwhelmed by demand" due to a combination of pre- and post-COVID factors, including staffing shortages and a significant backlog. While the department had begun outsourcing some of its backlog, this process was in its early stages, and no systemic overhaul had yet occurred. The health board has since established a better framework.
The coroner concluded that the nine-month delay was unacceptable and acknowledged by the health board. Sarah had been living with stage four cancer since October 2021. The delay was found to have reduced the chances of controlling her cancer through chemotherapy.
Although the medical cause of death was naturally occurring, the coroner issued a narrative conclusion to reflect the full circumstances of Sarah's death. The coroner apologized to Sarah's family for their loss and acknowledged the dignity they displayed throughout the proceedings.