A mother of three, Sarah Catherine Daniels, passed away from cancer after experiencing a nine-month delay in receiving her pathology test results. This delay meant she missed out on potentially life-saving treatment, as revealed during an inquest.
Her husband shared that Sarah “never gave up” in her battle against a rare and aggressive form of cancer. She died at the age of 43 in her home in Porth, Rhondda Cynon Taf, in April 2025.
Coroner Rachel Knight reported that the pathology department responsible for testing a mass found on Sarah’s ovary was “completely overwhelmed” due to demands heightened by the Covid-19 pandemic. She deemed the delay “unacceptable,” pointing out that it diminished the likelihood of successful chemotherapy.
The inquest revealed that Sarah first approached her GP in October 2021 with concerning gynecological symptoms. Her situation escalated when an ultrasound identified a mass on her ovary, prompting a referral to the gynecology unit within the Cwm Taf Morgannwg University Health Board.
Initially, she was presented with two surgical options: a total hysterectomy or a less invasive procedure to remove the mass. Choosing the latter, Sarah had the mass removed in February 2022, although pathology results indicated the mass did not appear cancerous.
Martin Ludlam, a biomedical scientist at the health board, stated that late 2021 and 2022 saw workloads surge due to a backlog created by postponed routine appointments during the pandemic. He admitted that they struggled to keep up with both current demands and the accumulated backlog.
By the end of 2022, the health board was no longer facing a backlog, thanks in part to outsourcing work, which Ludlam emphasized must become standard practice to prevent similar situations in the future.
Ben Daniels, Sarah’s husband, recounted how, upon receiving her results, Sarah learned that her cancer was terminal and her life expectancy was roughly 12 months. This prompted her to seek private treatment at the Christie cancer treatment center in Manchester, including the removal of her appendix.
Following this, she underwent additional treatments at Velindre Cancer Centre in Cardiff, where she received 10 rounds of chemotherapy. Although she initially received the all-clear, follow-up scans later identified a resurgence of cancer, complicating her treatment further.
Despite her determination, Ben noted that by January 2025, Sarah’s health had significantly deteriorated, and in March 2025, it was decided that she was no longer well enough for further chemotherapy.
Consequences of Delay
Sarah passed away on April 15, 2025, surrounded by those she loved. Mohamed Khalifa, a consultant involved in her care, highlighted the critical impact of the nine-month pathology delay on her treatment. He stated that, had treatment begun earlier, the outcome might have been different.
The coroner identified that while Sarah’s initial care was timely and appropriate — including her GP referral and MRI — there were lapses in the later phases of testing. She emphasized that the pathology department faced overwhelming demand and that outsourcing of the backlog was just starting to develop.
Ultimately, the coroner expressed that the nine-month delay had serious implications for Sarah’s cancer treatment and living conditions. She recorded Sarah’s cause of death as “metastatic signet ring adenocarcinoma of the appendix” but opted for a narrative conclusion, reflecting on the effects of the missed opportunities in her care.
Concluding the inquest, Knight expressed her condolences to Ben and their children, acknowledging the profound loss they experienced and recognizing the deep love surrounding Sarah.
