The conclusion of the Coroner following the Inquest touching on the death of Kerri Mothersole, Deceased was that "she died as a consequence of endometrial cancer, the diagnosis of which was delayed due to a number of factors".
During the Inquest, the Coroner heard that HEM Clinical Ultrasound Ltd had taken two ultrasound scans of the Deceased following referrals made by the Deceased's GP.
The first ultrasound scan report noted a large complex mass and recommended an urgent referral to the gynaecologists, blood tests (to check for ovarian cancer) and an MRI scan.
The second ultrasound scan report made no mention of a mass, but instead said there was suspected adenomyosis (though more serious pathology could not be ruled out) and suggested a referral to the gynaecologist; however, the second report did not state an urgent referral was required.
Only the second of the two reports were sent to the GP. None of the images were provided to any of the Deceased's treating clinicians including her GP, Medway Maritime Hospital or Maidstone Hospital.
The Coroner found that had the images and both reports been made available to the Deceased's treating clinicians, a more urgent referral would have been warranted by her GP, and she may have been investigated and treated at a much earlier stage.
The Coroner heard that most of Kent has a system where scans and x-rays can be shared between NHS Trusts and can even be linked to tertiary referral centres in London. The system used is referred to as the PACs system.
HEM Clinical Ultrasound Ltd gave evidence that they had requested that the images they take are made available on the central PACs system. They were unable to explain why this had not been set up or commissioned by the Integrated Care Board (ICB). The Coroner was concerned that unless action is taken by the Integrated Care Board, there is a risk that future deaths will occur.
The Coroner therefore made a Regulation 28 Report, which asks the ICB to take action regarding the fact that radiology taken in the community by private providers (contracted by the NHS) are currently not uploaded to the NHS central PACS system. Such imaging can be requested by NHS clinicians to be made available to them, but it relies upon the clinicians knowing there are images to access in the first instance. Therefore, when treating clinicians are unaware a patient has had imaging taken in the community, potential issues can be missed as occurred in the Deceased's case.
Read more about the case here:
https://www.kentonline.co.uk/sheerness/news/amp/we-shouldn-t-have-lost-our-mum-at-44-303884/