Mum died from aggressive cancer after nine-month wait for test results

A mum-of-three died from cancer following a nine-month delay in receiving pathology test results, meaning she did not receive potentially life-extending treatment fast enough, an inquest has heard.

Sarah Catherine Daniels' husband said she "never gave up" trying to fight her rare and aggressive cancer, but died at home in Porth, Rhondda Cynon Taf, aged 43 in April 2025.

Coroner Rachel Knight said the pathology department where a mass from Sarah's ovary had been sent for testing was at the time "completely overwhelmed by demand" following the Covid-19 pandemic.

She told the inquest at Pontypridd Coroners' Court that the delay was "unacceptable" and reduced the chance of successful chemotherapy.

Sarah first presented to her GP aged 39 in October 2021 with "gynaecological symptoms of concern", the inquest was told on Monday.

The matter was escalated by her doctor, resulting in an ultrasound scan on 21 October in 2021 which identified a mass on one of her ovaries. Sarah was then referred to gynaecology in the Cwm Taf Morgannwg University Health Board area.

She was given two surgical options, which included a total hysterectomy or a less invasive procedure to remove the mass.

The full hysterectomy would have triggered an early menopause as well as other effects, so the inquest was told that Sarah opted for the less invasive procedure.

In February 2022 the mass was removed, which did not have the expected appearance of a cancer, but samples were sent to pathology for testing.

Giving evidence, Martin Ludlam, a biomedical scientist who worked as the cellular pathology and mortuary service manager at the health board, said the situation at the time was difficult.

He said that during late 2021 and 2022 their workload significantly increased due to many routine appointments being put on hold during the Covid-19 pandemic.

He said they had an insufficient capacity to manage the current demand as well as the backlog.

Ludlam told the inquest that by the end of 2022 the health board was no longer dealing with a backlog in part due to outsourcing, which he said they were still using today.

"This case has highlighted the case that we can never go back to a position where we have a routine backlog again," he said.

Ben Daniels, Sarah's husband, gave written evidence and said when Sarah received her results she was told that her condition was terminal and that her life expectancy was 12 months.

He described how his wife was determined to get better and sought private treatment at the Christie cancer treatment centre in Manchester, which included the removal of her appendix.

Sarah then received follow up treatment at Velindre Cancer Centre in Cardiff which included 10 rounds of chemotherapy and scans.

She got the all clear, but some months later scans revealed that cancer was present.

This time Sarah struggled to have blood markers in the safe remit to receive regular chemotherapy, which meant treatment was "sporadic".

Ben said his wife "never gave up" trying to fight her illness but by January 2025 her health had gotten "progressively worse".

Dr Kein Yim, a consultant in clinical oncology at Velindre said that in March 2025 it was clear that her condition was declining and a decision was made that she was too frail for any more chemotherapy.

Sarah died at home in Porth on 15 April 2025, surrounded by loved ones.

Mohamed Khalifa, a consultant in obstetrics and gynaecology who leads gynaecological cancer multidisciplinary team (MDT) meetings for the Cwm Taf health board, gave evidence about the significance of the nine month pathology delay in Sarah's case.

He said that Sarah had lost time in her cancer treatment due to the delay between surgery and histology. He also said her Risk of Malignancy Index (RMI) had been "incorrectly reassuring" to her and her family.

"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 said.

Knight told the inquest that initial aspects of Sarah's care were dealt with in appropriate time, including her initial GP referral and her MRI scan on November 10.

The coroner said there was "low suspicion" that Sarah had cancer at that stage and that it was "reasonable" that medics did not seek an MRI scan of a wider area like her entire abdomen which may have revealed her appendix cancer.

She said evidence corroborated that the mass did not have the appearance of cancer, and that samples were sent "appropriately" to pathology for testing.

However, she noted that the pathology department was "completely overwhelmed by demand" due to pre and post-Covid factors including staffing and a huge backlog.

Drawing on evidence she stated that the department had begun outsourcing its backlog, but that this was in its infancy. At present she said there had been no "overhaul" of the system, but that a better framework had been established by the health board.

She said she found the nine month delay between Sarah's surgery and result "unacceptable", and noted that the issue was accepted by the health board. She said that Sarah had been living with stage four cancer since October 2021, and that the delay likely impacted her treatment as well as her quality and length of life.

She said the delay reduced the chance of success in cancer control through chemotherapy.

Sarah's medical cause of death was recorded as "metastatic signet ring adenocarcinoma of the appendix".

Although Knight noted that the medical cause of death was "naturally occurring", she opted for a narrative conclusion to reflect the full circumstances of Sarah's death.

Knight apologised to Ben and their children: "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."

She added it is clear "how loved Sarah was and how missed she is".