Risca mum Maria Shafighian died of cancer after referral left unread

Maria Shafighian, from Risca, died less than six months after being diagnosed.

The 59-year-old was first referred to the Ear, Nose and Throat (ENT) department at Aneurin Bevan University Health Board by her GP in late January 2020, with symptoms of 'persistent hoarseness'.

She was assessed by a specialist ENT trainee at the beginning of the following month, who ordered for a CT scan to be carried out, which found no signs of laryngeal cancer.

Mrs Shafighian was instead diagnosed with 'vocal cord palsy' - a condition in which a person cannot control the movement of the muscles that control their voice - and was referred to the Speech and Langauge Therapists (SALT) department.

During a video consultation in early April, 2020, the SALT team noticed she was suffering from swallowing difficulties; a 'worrying development' needing urgent assessment.

The SALT team referred Mrs Shafighian back to the ENT team and notified them of this development.

However, instead of directly communicating the urgent update between clinical teams, it was simply printed and left in the ENT pigeon hole where it went untouched for an entire month.

Senior coroner for the area of Gwent, Caroline Saunders, said: "During the inquest, I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system.

"Following assessment by SALT on May 4, 2020, a letter was written to the ENT team which was printed and left in a pigeon hole.

"No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner.

"In Maria’s case, there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team."

Following further assessment, she was diagnosed with oesophageal cancer - a throat cancer mainly affecting those in their 60s and 70s which is more common in men than women.

Mrs Shafighian was not a candidate for surgical intervention and received palliative chemotherapy and radiotherapy.

She died in late November 2020 - less than six months after being diagnosed - at the Ysbyty Ystrad Fawr community hospital in Ystrad Mynach.

Ysbyty Ystrad Fawr (Image: File)

Ms Saunders added: "In the inquest, I determined that there had been opportunities missed to identify and treat Maria’s tumour earlier, but I could not determine on balance that this would have altered the outcome and hence the conclusion was death by natural causes."

However she issued a Prevention of Future Deaths report into the case sent to the Aneurin Bevan University Health Board to which they have to reply.

She added that she had seen 'no evidence' that urgent matters such as cancer diagnoses were immediately brought to the attention of the relevant department.

Directly 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'.

Nicola Prygodzicz, the CEO of the Aneurin Bevan University Health Board (Image: NQ Staff)

Nicola Prygodzicz, the CEO of the Aneurin Bevan University Health Board, insisted in her response that the letter, which lay untouched in the pigeon hole for a month had also been sent electronically, which would then have been 'triaged' and sent to Central Registration for them to upload the letter onto the Clinical Workstation system.

At this point, she said, an acknowledgement would have been sent to Mrs Shafighian to inform her she had been added to the waiting list.

However, Ms Prygodzicz added it had been agreed that internal referrals such as Mrs Shafighian's should be sent directly to the Central Registration department and that any 'clinical developments' requiring an ENT opinion should also be emailed.

She added: "The Directorate is also in the process of developing a generic internal electronic referral form that would need to be completed for any patients needing ENT input or an opinion.

"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."