A mother of three died after waiting nine months for cancer test results, an inquest has heard.
Sarah Daniels, 43, from Porth, south Wales, faced what a consultant later described as an “unacceptable” delay after a cyst removed from her ovary was sent for testing. The mass was later found to be an aggressive and rare form of appendix cancer which had spread to her ovary.
By the time Sarah received the results, her condition was terminal and she was told she had around 12 months to live. The inquest heard she had first gone to her GP in October 2021 with “gynaecological symptoms of concern”.
Long wait for results
Sarah was offered two surgical options and chose a less invasive procedure rather than a total hysterectomy. The cyst was removed in February the following year and sent for testing, but Sarah then waited nine months for the results. The cancer, known as signet ring adenocarcinoma, had metastasised and spread to the ovary.
The inquest heard the pathology department at Cwm Taf Morgannwg health board had been “completely overwhelmed by demand” after being hit by a Covid “backlog” and “deluge” of work.
Biomedical scientist Martin Ludlam said the department’s workload had risen significantly after routine appointments were put on hold during the pandemic. Mr Ludlam said: “This case has highlighted the case that we can never go back to a position where we have a routine back log again.”
Treatment and outcome
In a statement, Sarah’s husband Ben said she was told her cancer was terminal when the results finally came back. But he said she remained determined to get better and underwent private treatment at the Christie cancer treatment centre in Manchester to have her appendix removed.
Sarah later received treatment at Velindre Cancer Centre in Cardiff, including 10 rounds of chemotherapy and scans. The inquest heard she was eventually given the all clear, before scans showed the cancer had returned just months later.
Ben Daniels said his wife “never gave up” fighting the disease, but her condition had become “progressively worse” by January last year. She died three months later in April 2025.
Coroner's conclusion
Consultant Mohamed Khalifa, who leads gynaecological cancer multidisciplinary team meetings for the health board, said earlier treatment could have made a difference.
He said: “When she died might have been different if the chemotherapy or other treatment had been started sooner. The delay of nine months between surgery and histology was unacceptable.”
He added that Sarah’s Risk of Malignancy Index had been “incorrectly reassuring” to her and her family. Her medical cause of death was recorded as “metastatic signet ring adenocarcinoma of the appendix”.
Coroner Rachel Knight recorded a narrative conclusion, finding Sarah’s death was “naturally occurring” but that the delay had reduced her chance of chemotherapy being successful. She said the wait for test results was also likely to have affected when Sarah died and her quality of life.
Addressing Ben at the inquest in Pontypridd, south Wales, Ms Knight said: “I’m sorry you lost Sarah in the way you did. You have shown great dignity throughout the proceedings. What you went though must have been horrendous It is clear how loved Sarah was and how missed she is”.
The coroner said the pathology department had since begun outsourcing its backlog.
