Mother, 59, dies from cancer after her referral for urgent medical help was left in a mail pigeonhole for a month, inquest hears
- Maria Shafighian, 59, died at the Ysbyty Ystrad Fawr hospital in November 2020
A mother died of cancer in a tragic hospital blunder after her referral for urgent medical help was left in a mail pigeonhole for a month, an inquest has heard.
Maria Shafighian, 59, missed a vital appointment when the letter was printed out and stuck in the pigeonhole for internal hospital mail.
Ms Shafighian, of Risca, in Caerphilly, died less than six months after being diagnosed with throat cancer, according to WalesOnline.
The letter from the speech and language therapists (SALT) went unread for a whole month after it was misplaced by staff at the Ear, Nose, and Throat (ENT) department, a coroner heard.
After the inquest in April senior coroner Caroline Saunders ordered a prevention of future deaths report to the health board.
Maria Shafighian, 59, (pictured) died of cancer in a tragic hospital blunder after her referral for urgent medical help was left in a mail pigeonhole for a month, an inquest heard
This found the mother died of natural causes after ‘opportunities missed to identify and treat Maria’s tumour earlier’.
The CEO of Aneurin Bevan Health Board, Nicola Prygodzicz, replied to the report saying the health board has since developed an internal electronic referral form.
Ms Shafighian’s condition got worse when she started having problems swallowing and a request was made for urgent assessment.
She had first been referred to the ENT department by her GP in January 2020 after experiencing hoarseness inside her throat.
She was then assessed by a specialist ENT trainee and a CT scan was ordered which found no signs of laryngeal cancer.
After being diagnosed with ‘vocal cord palsy’, Ms Shafighian was referred to the speech and language therapists department and underwent a video consultation in April 2020.
The mother missed a vital appointment when a letter for a referral was printed out and stuck in the pigeonhole for internal hospital mail
The SALT team later referred Mrs Shafighian back to the ENT team for an assessment while telling them of the ‘worrying development’ of of her swallowing difficulties.
This is when the referral was left in the ENT pigeon hole where it went untouched for a whole month.
Senior Gwent coroner Ms 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 pigeonhole.
‘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.’
Mrs Shafighian was eventually diagnosed with with oesophageal cancer – a type of throat cancer most commonly found in men in their 60s and 70s.
Ms Shafighian, of Risca, in Caerphilly, died less than six months after being diagnosed with throat cancer
She received palliative chemotherapy and radiotherapy after she was not a candidate for surgical intervention, and died less than six months later in November 2020. She passed away at the Ysbyty Ystrad Fawr community hospital in Ystrad Mynach.’
The coroner issued a prevention of future deaths report to the Aneurin Bevan University Health Board based at Royal Gwent Hospital in Newport.
She said that she had seen ‘no evidence’ that urgent matters such as a cancer diagnosis were quickly brought to the attention of the relevant department.
Talking to 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.’
MailOnline has contacted Aneurin Bevan Health Board for comment.