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Sara Grinnell

2024-0497
Prevention of Future Deaths Report

Coroner

Coroner's area

Date of report

Read the PFD report for

Patricia Morgan

South Wales Central

17 September 2024

Report recipients

Hospitals and other NHS acute settings

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

Issues raised
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