On25th March 2021 I commenced an investigation into the death of Serena Naomi Roberts. The investigation concluded on the 10th September 2021 and the conclusion was one of Narrative: Died from a complication of ovarian cancer not diagnosed until after her death. When referral to secondary care was delayed, and her risk factors not fully recognised when triaged by secondary care. The medical cause of death was 1a Septic Shock 1b Intra-abdominal sepsis. 1c Ovarian Cancer II Morbid obesity

Serena Naomi Roberts was referred in April 2020 for an ultrasound scan having reported symptoms of recurrent very heavy vaginal bleeding. Her BMI was high. The ultrasound was only able to report a partial view. It indicated endometrial thickness and lack of success in scanning her ovaries. It was recommended she be referred to a gynaecologist for review. The GP who saw her to discuss her scan did not refer her to a gynaecologist. In November 2020 at a consultation the GP realised a referral had not been made and made one. The letter was marked urgent. The e-referral completed by the surgery marked it as routine. The referral was limited in detail and did not reference her BMI which NICE guidance on managing heavy menstrual bleeding makes clear is a risk factor. The referral letter lacked details of the heavy bleeding and treatment. The triage by the gynaecology team at Tameside General Hospital put the referral as routine. It is unclear the basis on which the decision was made given the delayed referral and the presentation and the findings of the May ultrasound. In a series of telephone appointments following November 2020, the treating medical staff at the GP practice did not recognise that she had not yet seen a gynaecologist despite the request to see her urgently and it was not chased up. On March 4th, 2021 she attended A+E at Tameside General Hospital due to her pain and heavy vaginal bleeding. She was discharged with painkillers. There was to be a call from emergency gynaecology for an ultrasound scan. This did not happen. On 9th March there was a telephone consultation with a consultant gynaecologist who referred her for a transvaginal ultrasound. The appointment was not face to face due to Covid. As a consequence, Serena Roberts was not examined, and her BMI was not recognised. On 20th March 2021 Serena Roberts attended Tameside General Hospital as an emergency patient. She was operated on and found to have a mass that was tube/ovarian and extensive peritonitis. Histology later confirmed that the mass was an ovarian cancer with a significant tumour necrosis. Earlier referral as an urgent case to specialist and to secondary care would on the balance of probabilities have given the opportunity to identify the ovarian cancer at an early stage put in place an earlier treatment plan to manage her cancer.