Dear Mrs Morgan

Regulation 28 Report to Prevent Future Deaths

I am writing in response to the Regulation 28 Report issues to Cwm Taf Morgannwg University Health Board (CTMUHB) on 17 September 2024 following the conclusion of the inquest into the death of Sara Grinnell.

The Health Board values the opportunity to learn from the tragic events relating to Sara’s death. The Regulation 28 report identified three key areas of concern listed below:

(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks to contact the patient with an urgent appointment. (2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P. (3) When the G.P. re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.

Cyfeiriad Dychwelyd/ Return Address: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg Pencadlys Parc Navigation, Abercynon CF45 4SN

Cwm Taf Morgannwg University Health Board Headquarters Navigation Park Abercynon CF45 4SN

Ffôn/Tel:

Cadeirydd/Chair: Prif Weithredwr/Chief Executive:

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response.

As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis.

This response is limited to the actions taken by CTMUHB in relation to the Coronial concerns, each of which will be responded to individually in order to provide assurance on the improvement actions implemented.

1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks to contact the patient with an urgent appointment. The Welsh Government has established clear guidelines for managing referral-to- treatment waiting times to ensure timely access to care. Under the mandate issued in December 2009, all referrals to secondary care are expected to be addressed within 26 weeks for at least 95% of cases.

Ms. Grinnell’s waiting time of 22 weeks, though understandably lengthy, was within the official timeframe for urgent cases. It is important to note that only a referral marked as “urgent suspected cancer” would have triggered a more accelerated pathway in line with NHS guidelines, designed to expedite diagnosis and treatment for cases suspected of malignancy.

With the benefit of hindsight, it might have been beneficial for Ms. Grinnell’s referral to have been designated as “urgent suspected cancer” initially, which may have allowed for management under the national single cancer pathway for endometrial cancer.

2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P.

Our primary communication method with Ms. Grinnell has consistently been written correspondence. We made three documented attempts to reach her on November 21st, November 28th, and December 12th, 2019. Historically, written communication has been effective, as evidenced by Ms. Grinnell's response to a January 2018 letter, which she received and then attended the scheduled appointment.

Following her GP’s urgent suspected cancer referral, we continued to communicate primarily by letter, a method proven both adequate and effective in delivering essential information. Additionally, on May 28th 2019, there is documented evidence of a telephone conversation between Ms. Grinnell and hospital management, which occurred shortly after her urgent referral to secondary care, following the 24-hour response protocol.

There is no indication that an alternative communication method would have increased Ms. Grinnell’s likelihood of attending any appointments during 2019– 2020, particularly given the heightened difficulties posed by the pandemic. It is also notable that from January 2019 to December 2020, Ms. Grinnell did not initiate contact with her GP. Her next recorded contact with the GP occurred in January 2021.

Cadeirydd/Chair: Prif Weithredwr/Chief Executive:

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response.

3) When the G.P. re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.

The Health Board respectfully does not agree. Following Ms. Grinnell’s referral for worsening symptoms, her case was reviewed by both her GP and a specialist, who determined that her symptoms did not meet the criteria for an urgent suspected cancer (USC) referral. Despite this assessment, multiple attempts were made to contact her. Ultimately, Ms. Grinnell was removed from the waiting list due to a period of non-engagement with healthcare providers.

A letter dated 12th December 2019, sent to both Ms. Grinnell and her GP, explicitly stated that should her condition become a renewed concern, she could be reinstated on the waiting list within three months. This correspondence provided both Ms. Grinnell and her GP with a direct telephone number for the booking office, should re-engagement be necessary. The letter reflects a proactive approach, carefully considering her symptoms and incorporating safety-netting measures to mitigate the risk of a missed follow-up opportunity.

As no further contact was made by Ms. Grinnell or her GP within the specified period or throughout 2020, it is reasonable to conclude that she exercised her autonomy in choosing not to seek further care—a decision that healthcare providers must respect.

The Health Board would like to reiterate that no communication was received from Ms. Grinnell or her GP until January 2021. In our view, the period before January 2021 represented the critical window for early intervention. However, the missed opportunity here is multifactorial, influenced by apprehension about hospital visits during the COVID-19 pandemic and the challenges in healthcare delivery due to pandemic-related pressures.

As a Health Board, we endeavour to achieve required standards of care for women. An improvement plan for Urgent Suspected Cancer referrals has been developed and included within this response for assurance.

I hope that this response provides explanation and assurance that CTMUHB are committed to fully address the concerns in the Regulation 28 Report relating to Sara Grinnell’s death.

Please do not hesitate to contact Dr Dom Hurford, Executive Medical Director if you would like further assurances or if you require a meeting to discuss any areas of continuing concern.