A retired history teacher from Essex died after facing a series of critical delays in her cancer diagnosis and treatment at an NHS hospital, an official investigation has concluded.
‘Delay after delay’ in vital care
The Parliamentary and Health Service Ombudsman (PHSO) found that failings by Mid and South Essex NHS Foundation Trust caused distress and contributed to the early death of the 67-year-old woman, identified only as Mrs S. The mother-of-two from Chelmsford passed away in 2023.
Mrs S, an active volunteer, choir singer, and tennis player, first visited her GP in January 2023 with symptoms of abdominal bloating. She was referred to the trust, but her path to treatment was beset by hold-ups.
Her CT scan took place on 16 February, a biopsy followed on 15 March, and she finally received a diagnosis of terminal ovarian cancer on 21 March. Doctors told her chemotherapy could extend her life.
Missed targets and a missed chance
The PHSO report detailed a stark timeline. Mrs S's diagnosis took 49 days, far exceeding the NHS target of 28 days from referral. Her treatment did not start until 81 days after referral, against a target of 62 days.
Critically, the ombudsman stated that if the trust had met national standards, she would have begun chemotherapy on 3 April 2023, when she was still well enough to tolerate it. By the time her treatment was scheduled a month later, her health had deteriorated too far.
"I had trust in the NHS, so whenever they told us things like scans would happen, we believed them. But it was just delay after delay," said her 31-year-old son, a chartered surveyor.
"After we finally had the diagnosis, we were almost relieved and we expected treatment to start straight away. But again, it took too long," he added, describing the experience as "confusing and frustrating."
Trust performance under scrutiny
The investigation revealed wider concerns about the trust's performance on cancer wait times. While the trust claimed improvements, data showed a decline. In February 2023, only 47.6% of cancer patients started treatment within the 62-day target. By July 2025, this figure had dropped to 46.1%.
The PHSO has ordered the trust to apologise formally to Mrs S's family and to conduct a review of its cancer waiting times. It also recommended the trust create a robust plan for improvement.
PHSO Chief Executive Paula Sussex said: "While this will sadly not change what happened in this case, it highlights how one complaint can make a difference. Because of this investigation, other patients and families should experience wait times that are in line with national guidance."
Dawn Scrafield, chief executive of Mid and South Essex NHS Foundation Trust, offered "sincere apologies" to the family. She acknowledged increased demand and said the trust had begun an improvement plan, adding: "We can already see our wait times reducing in some cancers as we deliver extra clinics."
Mrs S's son also recounted "nightmares" about his mother being unsafely discharged without support before her death. He believes that with timely care, her quality of life would have improved and they might have had more precious time together.
